Inspection on 19/03/07 for Sansigra

This inspection was carried out on 19th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Sansigra 14/08/08

Sansigra 10/03/08

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 Stephen Baber Unannounced Inspection 19th March 2007 09:30 Sansigra DS0000009166.V333405.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.V333405.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.V333405.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 Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Sansigra DS0000009166.V333405.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 24th October 2005 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.V333405.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an annual key inspection, which took place on 19th March 2007 and was unannounced. It lasted for approximately six hours. Information about the home received by the Commission since the previous inspection was taken into account when planning the inspection. The purpose of the inspection was to ensure that service users’ needs are appropriately met in the home, with particular regard for ensuring good outcomes for them. This involved interviews with three service users, the one care assistant and the registered providers and observation of the daily life and care provided. There was an inspection of the home’s premises and of written documents concerning the care and protection of the service users and the ongoing management of the home. Staff were interviewed and observed in relation to their care practices and there was a discussion with the providers with Mrs Penellum being the registered manager. The principle method used was case tracking. This involves examining the care notes and documents for a two service users and following this through with interviews with/ observation of them, staff working with them. This provides a useful, in-depth insight as to how service users needs are being met in the home. Mr and Mrs Penellum said to me that the home is run in the style of a large family home with all the dynamics of interaction associated with that. They live on site and carryout all the sleeping in duties between them. There was evidence throughout of investment with high standards of accommodation. Mr and Mrs Penellum said the aim of the service is for the service users to receive a quality service with the support of the providers and care assistant. What the service does well: The service users are well matched as a group and appeared to get on well with each other. Prior to their admission they were provided with information about the home and are encouraged to visit and spend some time to talk with other service users and looking at the services and facilities. The home is reliant on a proprietary recording system for care planning and a whole range of assessments, which may be regarded as suitable for the Sansigra DS0000009166.V333405.R01.S.doc Version 5.2 Page 6 current service users who have low to medium dependency. The recording system sets out how the home will meet their personal, health and social care needs, including needs relating to their individual backgrounds and culture, age, sex, religion, individual abilities and sexual orientation. Service users are encouraged to make important decisions about their lives, such as what activities to take part in during the week and how to spend their free time so that they develop their confidence and independence. Identified risks are carefully managed, to minimise restrictions on service users and enable them to take part in activities that develop their skills and enhance the quality of their lives. Service users enjoy a good quality of life in the home. The providers support them to take part in a wide range of activities in the home and the local community, which vary according to their individual needs and preferences. Activities are age and culturally appropriate for them. They attend a variety of social activities including visits to pubs and cafes in the community. Service users are actively supported and encouraged to maintain contact with their families so that they maintain and develop valued relationships outside of the home. They take part in planning; shopping and all three gentlemen said they enjoy the meals they receive and karaoke evenings. The providers and staff help the service users to independently attend to their personal care and they all looked clean and smartly dressed. The emphasis is on “Normalisation” similar to the way people would access services in the community with all service users accessing a range of NHS healthcare providers, such as doctors, opticians and specialist services when they need them so that they maintain good general health. Medication is safely stored in the home and Mrs Penellum referred to from now as the registered manager taking responsibility for the administration and dispensing and disposal of medication. The manager has completed a distance-learning package into the safe handling of medication in 2006. There are policies and procedures on medication. Management encourage the service users and their relatives to make their views known and are taken seriously, especially if they wish to complain about any aspect of their care. There are systems in place to ensure that they are safe and well cared for in the home. There is only one care assistant and one domestic employed. Management do all other hours. The magnitude of this task is not too much as management said they love the work. Their two daughters assist them when necessary. The home’s environment provides service users with a comfortable and homely setting in which they can develop their skills and independence and be part of a local community. It was clean and tidy throughout at the time of the inspection, which was unannounced. The home is generally well managed for the benefit of the service users. The manager is registered with the Commission as a fit person to run the home on a day-to-day basis. Service users and their representatives are given opportunities to contribute their views and opinions to the ongoing planning, Sansigra DS0000009166.V333405.R01.S.doc Version 5.2 Page 7 development and improvement of the service and the quality assurance carried out in 2006 included an ongoing development plan for the home based on a systematic cycle of planning–action-review aims and outcomes for service users. What has improved since the last inspection? What they could do better: The providers were given comprehensive feedback on the findings of the inspection. An open discussion took place on the findings of the inspection and valid points were raised on both sides. Systems of recording have been set up and evolved without too much deviations and improvement. This inspection identified areas that could be improved on and would enable the providers to move forward in line with best practice, the regulations and national minimum Sansigra DS0000009166.V333405.R01.S.doc Version 5.2 Page 8 standards. The following recommendations are made to improve the service to the service users. Daily records and service user care plans. Daily recording at present is very basic and does not reflect the individual lifestyle of the service users. Daily recording should be expanded to reflect the needs, aspirations and goals met for each service user. The daily recording should be developed as the service users life and circumstances change. Service users files should be individualised to comply with The Data Protection Act 1998. The current system of keeping all records together allows for people to look at other people’s files and confidential information in them. Care plans should be provided to service users in more meaningful ways, with clear and specific goals, outcomes achieved each review and by whom. This enables service users to participate more directly in making decisions and gives greater control over their lives. A further development of the care plan would be to have them translated into pictorial formats for them so that the information is more accessible and meaningful to them. This would enable service users to understand them more easily. Recruitment, selection and vetting of staff. Application forms should record the last ten years of employment. The last person appointed did not detail this on their application form. Adult Protection and Complaints The providers stated that they have in 2006 completed a distance learning training package in adult protection It is recommended that that the providers attend the multi-agency training in this respect, to gain familiarity with the way in which organisations should work together to protect vulnerable adults from abuse. This can then be cascaded to staff. The manager is trying to obtain a copy of the multi agency guidance on Adult Protection. The complaint procedure should record details of the Adult Social Care department as they have a statutory responsibility to investigate complaints. Sansigra DS0000009166.V333405.R01.S.doc Version 5.2 Page 9 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.V333405.R01.S.doc Version 5.2 Page 10 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.V333405.R01.S.doc Version 5.2 Page 11 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): Standard 2 was assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users undergo detailed assessments prior to their admission to the home so that they can be confident it will be suitable to meet their needs EVIDENCE: The home has accommodated the same service users for a long time. The service users appeared to be well matched and those who were interviewed confirmed that they get on well together as a group. There is assessment and review information on their personal files to show that their needs are being monitored and reviewed. The three service users I spoke with said the providers are very good to them and they can access all parts of the home freely. They went on to tell me that when they have visitors they are made to feel welcome and can entertain them in their own rooms or communal areas. Sansigra DS0000009166.V333405.R01.S.doc Version 5.2 Page 12 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): Standards 6,7, and 9 were inspected. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are aware of their care plans, which address their health, social and personal care needs in full, including needs relating to their age, sex, sexual orientation, disability, cultural and ethnic backgrounds and religion. They would benefit from more detailed and specific goals to work towards so that they can monitor their own progress and achievements. They are encouraged to develop their skills in making decisions for themselves to develop their confidence and independence and to take managed risks. EVIDENCE: Service users interviewed were aware of their care plans and confirmed that they attend their reviews. Copies of care plan summaries and identified risks are all held in one book. It is recommended that each service user has their own individual file and that consideration be given to translating the care plans into meaningful formats for service users to follow. It is also recommended that care plans have specific outcomes, goals and timescales and with the name of the person who has to achieve this. The service users told me that reviews are held and information is shared with them. As evidenced from the Sansigra DS0000009166.V333405.R01.S.doc Version 5.2 Page 13 reviews they are shared with the service user and take place every six months. I am led to believe that there has not been any formal review by social workers of the Adult Social Care department. This has to be followed through by the providers as a priority. Service users were observed making choices about what activities to engage in during the inspection and about what they would like for lunch. The manager undertakes the daily recording. Daily recording at present is very basic and does not reflect the individual lifestyle of the service users. Daily recording should be expanded to reflect the needs, aspirations and goals met for each service user. The daily recording should be developed as the service users life and circumstances change. A proprietary recording system is used to provide written risk assessments for each of the service users on their personal files to guide staff on how to enable them to take risks to develop their skills and independence in managed ways. The manager is happy with this current system of assessment, which has proforma documents and involves ticking boxes with dependency scoring to identify risks and hazards. The home has a lockable office, so that confidential information relating to service users can be safely stored away. The manager is mainly responsible for record keeping. Sansigra DS0000009166.V333405.R01.S.doc Version 5.2 Page 14 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): Standards12, 13,15,16and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users access a range of activities, in accordance with their individual needs and preferences, so that they develop their skills and independence. They regularly access resources in the local community and are supported to maintain valued relationships with their friends and relatives so that they are not isolated and they enjoy a good quality of life. Their rights and responsibilities are recognised and promoted as far as is practicable. Service users receive a nutritious, well balanced and varied meals and said they are happy with the catering arrangements. EVIDENCE: The home’s records and my conversations with the providers and service users confirmed that service users were engaging in different activities in and out of the home during the day. Service users said or indicated that they enjoy a good lifestyle in the home and are satisfied with the activities provided. Service users were observed accessing community resources during the day. Service users participate in a variety of activities such as day centres, Sansigra DS0000009166.V333405.R01.S.doc Version 5.2 Page 15 sheltered work placements and adult education. Service users are able to participate in a range of leisure pursuits accompanied by the registered providers. Service users rights are respected. Times for getting up and going to bed are flexible-although service users participate in some activities (e.g. going to the day centre), which require an early morning start. There are no locks on bedroom doors. This issue has been discussed at service user meetings and current service users have said they do not want these. Any new service user must be offered a lock on their bedroom door if they have the capacity to use this. Toilet and bathroom facilities are however lockable. Service users receive appropriate assistance with their mail. Service users are able to access any part of the home or its grounds and are addressed by the name of their choice. The Environmental Health Officer last inspected the premises in 2005 and was very satisfied with the cleanliness of the kitchen and “Due Diligence” demonstrated by the providers. The manager said that all the service users have good appetites and enjoy their meals. The service users I spoke with confirmed this. Service users can make choices at breakfast and lunchtime and said or indicated that they enjoy meals in the home. Service users do not assist in the preparation of meals. Sansigra DS0000009166.V333405.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19 and 20 were inspected. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are helped to maintain and develop their independence with regard to their personal care. They are assisted to access healthcare services they need so that they stay well and enjoy their lives. Arrangements for managing medicines are safe. EVIDENCE: Service uses looked smart and well cared for. All the service users are quite capable to manage their personal care needs and staff are on hand to offer help and support with their self-care so that they can develop their skills and independence. The home’s records show that service users are helped to access a range of NHS healthcare providers to maintain good general health and specialist services according to their individual needs. All the service users at present enjoy good health. The home has safe arrangements for the storage, dispensing and disposal of medicines. Records evidenced that medicines are and properly administered to service users with Mrs Penellum taking full responsibility for this task. There Sansigra DS0000009166.V333405.R01.S.doc Version 5.2 Page 17 are policies and procedures on medication. The manager has undertaken training in the safe handling of medicines through distance learning training package. Sansigra DS0000009166.V333405.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are formal and informal systems in place so that service users’ views are taken into account in the day-to-day running of the home. Service users’ welfare and best interests are well protected so that they feel safe and well cared for in the home. EVIDENCE: Service users interviewed said that they are satisfied with the care and services provided to them at the home. Records in the home indicate that there have not been any formal complaints recently. It is recommended that the inclusion in the complaints procedure of Adult Social Care department should be included as they have a statutory responsibility to investigate complaints on behalf of service users who have commissioned services on behalf of them. Service users and their representatives are given opportunities to contribute their views and opinions to the ongoing planning, development and improvement of the service and the quality assurance carried out in 2006 included an ongoing development plan for the home based on a systematic cycle of planning–action-review aims and outcomes for service users. Service users interviewed said that they feel safe in the home. The home’s written procedures to guide staff on what action to take if they suspect a service user has been abused should be updated so that they have clear information on what to do to protect them. The providers have completed a distance learning training package in adult protection. It is recommended that that the providers attend the multi-agency training through Cornwall Adult Sansigra DS0000009166.V333405.R01.S.doc Version 5.2 Page 19 Social Care department. This will help them gain familiarity with the way in which organisations should work together to protect vulnerable adults from abuse. This can then be cascaded to staff. The manager is trying to obtain a copy of the multi agency guidance on Adult Protection. Sansigra DS0000009166.V333405.R01.S.doc Version 5.2 Page 20 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): Standards 24 and 30 have been assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a comfortable, safe and homely environment so that they can develop their skills and independence in a non-institutionalised setting. Good hygiene is maintained so that service users are adequately protected from infection. EVIDENCE: Sansigra is a detached house in the village of Zelah. It is an impressive property set in its own grounds and well situated to Truro. It appeared well decorated and there was evidence of significant investment to improve the facilities inside and outside the home. Service users appeared to be comfortable and enjoyed the services and facilities available to them. The gentlemen were observed to be doing what they wanted on the day of the inspection and said to me that they are very satisfied with the home’s environment. Sansigra DS0000009166.V333405.R01.S.doc Version 5.2 Page 21 The home appeared 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 service users from cross-infection. Suitable facilities are in place to ensure good hand hygiene and shower trays and baths were clean. Paper towels and antibacterial soap is provided in all toilets and bathrooms. Sansigra DS0000009166.V333405.R01.S.doc Version 5.2 Page 22 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): Standards 34, 35 and 36 were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The one care assistant has NVQ level 2. Service users can have confidence in staff ability to work competently with them. Recruitment policies and practices are fair, safe and effective so that staff are employed on the basis of their suitability to work with vulnerable adults in a care setting and staff are provided with training albeit through distance learning training. This ensures that they have the skills they need to work safely. Staff are well supported and are provided with regular formal supervision so that service users can be assured that they are properly supervised. EVIDENCE: There is one care assistant and one domestic employed. The daughters of the providers assist where necessary. The provider’s do the majority of the day and night cover at the home. The care assistant is qualified to NVQ level 2. The domestic has only just commenced employment and is currently undergoing her induction training. Records held in the home indicate that staff are recruited on the basis of formal applications, equal opportunities interviews and checks to ensure they are suitable to work in a care setting. However staff should record on their Sansigra DS0000009166.V333405.R01.S.doc Version 5.2 Page 23 application forms the last ten years of employment. CRB’s were inspected and it is recommended that a system is set up to record CRB’s as the guidance for the disclosure from criminal records bureaux is that they have to be destroyed within six months. New staff undergoes Skills For Care Induction training to equip them to work in the home. The manager monitors staff training via the staff-training plan. Records of individual one-to-one supervision of care staff were inspected and it was evident that management support them to do their job well. Sansigra DS0000009166.V333405.R01.S.doc Version 5.2 Page 24 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): Standards 37,39 and 42 were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is generally well run for the benefit of the service users living there. Service users are able to contribute their views to the ongoing management of the home. The home is kept safe for service users so that service users are adequately protected from obvious hazards and potential accidents. EVIDENCE: The service users said that they are well looked after by the providers who work very closely with the everyday. The providers are registered with the Commission as fit persons to undertake the running of the home on a day-today basis. They have many years experience of caring for people and know the service users well. The manager undertakes regular training to update her knowledge and skills. Sansigra DS0000009166.V333405.R01.S.doc Version 5.2 Page 25 Service users and their representatives have formal and informal opportunities to contribute their views to the running of the home. A formal quality assurance exercise was carried out in 2006 and the results of the surveys were very positive with service users and their representatives confident that their views underpin all self-monitoring, review and development by the home. There are records in the home to evidence this The providers live onsite and ensure that service users are provided with a safe environment through written guidance, regular equipment tests and checks, with records kept and written risk assessments. Service users with whom I spoke said that they feel safe in the home and there are low rates of recorded accidents. There is an emergency contingency plan in place and agreed by the fire authority should there been an unforeseen incident whereby service users would have to leave the home. Sansigra DS0000009166.V333405.R01.S.doc Version 5.2 Page 26 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 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 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 3 X 3 X X 3 X Sansigra DS0000009166.V333405.R01.S.doc Version 5.2 Page 27 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. Standard Regulation Requirement Timescale for action 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 YA6 Good Practice Recommendations The registered persons should provide service users’ care plans to them in meaningful format, which are directly accessible to them, with clear outcomes, time scales and specific goals. Reviews by the statutory body should be carried out to ensure that the total needs of the service users are being met. The registered persons should include in the complaints procedure the name, address and telephone number of the Cornwall Adult Social Care department who have a statutory duty to investigate complaints on behalf of service users whom they have commissioned care for. The registered persons should update the policy and procedure on Safeguarding Adults and undertake the Multi Agency training in Adult protection with Cornwall County Council. The registered persons should request from all prospective applicants that they give them the last ten years of employment. The guidance on CRB’s should be followed DS0000009166.V333405.R01.S.doc Version 5.2 Page 28 2 YA22 3 YA23 4 YA34 Sansigra regarding the destruction of the disclosure after six months. Suitable recording systems should be set up to record the relevant details. Sansigra DS0000009166.V333405.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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.V333405.R01.S.doc Version 5.2 Page 30 - 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!