Inspection on 22/05/07 for Saresta and Serenade

This inspection was carried out on 22nd May 2007.

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

The inspector 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

Saresta and Serenade 24/05/06

Saresta and Serenade 12/10/05

Saresta and Serenade 04/05/05

Saresta and Serenade 30/11/04

Saresta and Serenade 19/05/04

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

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Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

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

CARE HOME ADULTS 18-65 Saresta and Serenade Bromley Road Elmstead Market Colchester Essex CO7 7BX Lead Inspector Ray Finney Key Unannounced Inspection 22nd May 2007 09:30 Saresta and Serenade DS0000017927.V341172.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 Saresta and Serenade DS0000017927.V341172.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. Saresta and Serenade DS0000017927.V341172.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Saresta and Serenade Address Bromley Road Elmstead Market Colchester Essex CO7 7BX 01206 827034/825779 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) Mr Rohan Vasantha Kumara Dias Mrs Velamba Dias Ms Karon Bosher Care Home 10 Category(ies) of Learning disability (10), Physical disability (10) registration, with number of places Saresta and Serenade DS0000017927.V341172.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home accommodates 10 people with learning disabilities who may also have physical disabilities 24th May 2006 Date of last inspection Brief Description of the Service: Saresta and Serenade is situated in the village of Elmstead Market. There is a local shop and garage nearby and the town of Colchester is a short bus or car journey away. There is a car park to the front of the property and wellmaintained gardens to the rear. The home provides care and accommodation for up to ten people with learning disabilities between the ages of 18 and 65, some of whom may have a physical disability. The home consists of two separate bungalows, each accommodating five people in single rooms with en-suite facilities. Each bungalow has living accommodation, kitchen and its own laundry facilities. The home is owned by Mr and Mrs Dias and is one of a small consortium of homes in the area. The manager of the home is Ms Karon Bosher. Information about the service may be obtained by contacting the manager. The home charges between £750 and £1,200 a week for the service they provide. This information was provided to us in May 2007. Saresta and Serenade DS0000017927.V341172.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A range of evidence was looked at when compiling this report. Documentary evidence was examined, such as menus, staff rotas, care plans and staff files. Completed comment cards were received from relatives and visiting professionals. The manager submitted an Annual Quality Assurance Assessment with information about the home (throughout the report this document will be referred to as the AQAA). A visit to the home took place on 22nd May 2007; this included a tour of the premises, discussions with the manager and members of staff. Observations of how members of staff interact and communicate with people living in the home have also been taken into account. On the day of the inspector’s visit the atmosphere in the home was relaxed and welcoming and the inspector was given every assistance from the manager and members of staff. What the service does well: What has improved since the last inspection? An ongoing programme of redecoration continues to make the environment better for people living in the home. In particular a new bathroom has been installed with a Jacuzzi bath and an electronic hoist with overhead tracking. This has created an excellent environment that enhances the bathing experience for people living there. Saresta and Serenade DS0000017927.V341172.R01.S.doc Version 5.2 Page 6 The manager has developed the Quality Assurance process to ensure the views of people living in the home and their representatives are taken into account. The process for supervising staff has improved, with individual one to one supervisions taking place more regularly. People living in Saresta & Serenade can be confident they are cared for by a well-supervised staff team. Overall record keeping is better in the home and people living there may be assured that issues relating to their care are appropriately documented. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Saresta and Serenade DS0000017927.V341172.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 Saresta and Serenade DS0000017927.V341172.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People choosing to live at Saresta & Serenade can be confident their needs will be assessed before admission. EVIDENCE: Information from the AQAA states that home carries out a “complete, comprehensive assessment of individual needs” and offers the option of staying for a trial period to anyone wishing to move to the home. The manager is able to demonstrate a good awareness of the importance of a detailed assessment. There have been no new admissions in the past 12 months but one person has recently moved out so there is now a vacancy. On the day of the inspection visit the manager discussed how they are looking at compatibility with other people living in the bungalow and how this impacts on the assessment process. Records examined confirm that the home has an appropriate assessment process in place. Saresta and Serenade DS0000017927.V341172.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in Saresta & Serenade benefit from a well developed care planning system. They are supported to make decisions about their lives and to take risks within their capacity to understand. EVIDENCE: The manager provided information in the AQAA that people’s likes and dislikes are recorded in care plans based on information from care plan meetings, reviews and input from relatives and staff. Although people living in the home have complex needs, some people can communicate their wishes using communication boards and pictures. A sample of three care plans was examined. These identify the person’s need, objectives and an action plan of how to meet the need. The care plans cover the four main areas of Personal Hygiene, Social Skills, Independent Living and Personal & Physical well being. Individual files contain a comprehensive array of care plans covering continence, awareness of danger, socialising, eating, Saresta and Serenade DS0000017927.V341172.R01.S.doc Version 5.2 Page 10 personal care, activities, shopping and independent living. around emotional and physical well-being is good. The information Positive aspects of what the person can do are identified in the care plans and independence to whatever degree possible is encouraged. Encouragement is emphasised throughout the care plans. Care plans are evaluated every three months and keyworkers complete monthly reports. Staff spoken with are able to demonstrate a good awareness of people’s individual needs. Information from the AQAA indicates that staff support people with making decisions. This was confirmed on the day of the inspection visit by watching interactions between staff and people living in the home. The complex needs of people in home means staff have to be skilled at reading the signs and signals that are part of the person’s way of communicating and staff were observed to be competent at this. Records examined show that if there are limits to someone’s ability to make choices it is documented in the care plan. Staff spoken with are able explain how they support people with little or no verbal skills to make choices. As previously reported, no service users have the capacity to manage their own finances and all have appointees to do this for them. The home continues to have an appropriate process around assessing risk. Records examined contain risk assessments relating to care plans. Records examined show that if there are limits to someone’s ability to make choices it is documented in the care plan. From observation of staff practices such as using wheelchairs it is clear that they are aware of the risks involved in supporting the people they work with. Saresta and Serenade DS0000017927.V341172.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, 14, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home have opportunities to participate in activities that are appropriate to their needs and they are supported to access facilities in the local community. The home ensures that people living there build and maintain relationships with their families. The people living in Saresta & Serenade benefit from a well balanced, nutritional and varied diet. EVIDENCE: All the people living in Saresta & Serenade have complex needs and are unable to undertake paid employment or to attend college or educational facilities. However, the home continues to encourage people to participate in a variety of stimulating activities. Information is provided in the AQAA that, by taking the views of people in the home and their representatives into account, it has helped the staff team to Saresta and Serenade DS0000017927.V341172.R01.S.doc Version 5.2 Page 12 develop an activity programme to meet individual wishes and to reduce the number of group activities that have taken place in the past. The manager discussed how they make the best use of staff time and one-to-one funding for individuals so that everyone living in the home benefits from a variety of activities. Records examined confirm that activities include the use of a sensory room or Snoozelen, trampolining at Bounceability, swimming, Gateway Club, hydrotherapy and aromatherapy. Staff spoken with confirm that people are also supported to go shopping on a one-to-one basis. The AQAA states that the home ensures people are included in regular food shopping trips and discussion with members of staff confirms this. Records indicate that social and recreational activities taking place within the community include walks to the village, pub visits and Gateway Club. Care plans contain evidence that community facilities such as local supermarkets, hairdresser and swimming pool are used. The manager identified in the AQAA that lack of funding for holidays and activities can make it difficult for individual one-to-one holidays to be arranged. In the past, going as a group has enabled holidays to take place. The manager discussed how she is looking at ways of making holidays more individual. Discussions with the manager and staff indicate that the home supports people to maintain good family links. Records examined contain evidence that relatives attend social activities such as parties and barbecues and are proactive in supporting their relatives’ care. A large joint Christmas and birthday party helped relatives to get together and form closer links. This has resulted in mobility funding being used to lease a new minibus the use of people living in the home. Staff and relatives feel that this will make accessing activities easier and ensure travelling is a better experience for individuals. The manager believes that communication is now better between relatives and the home. People living in the home who have complex learning disabilities and physical needs are unable to take an active part in daily household routines but observations on the day of the inspection visit show that they are encouraged to be involved to whatever degree they are capable. One person is encouraged to watch kitchen activities such as food preparation safe distance as their extreme behaviour would present a high risk even when supervised in the kitchen. Staff make sure they involve the person in conversation about what they are doing. Staff are developing a vegetable garden and now have a greenhouse so that people living in the home can be encouraged to assist staff with growing vegetables. The manager said that they hope this will help develop an awareness of healthy eating. Records examined contain information about the specialist nutritional needs, such as pureed food and PEG feeds, that some people living in the home Saresta and Serenade DS0000017927.V341172.R01.S.doc Version 5.2 Page 13 require. Individual likes and dislikes are also well documented. Staff spoken with are able to demonstrate a wide knowledge of people’s tastes, likes and dislikes. A tour of the premises confirms that a wide variety of food is available. On the day of the inspection lunch was observed to be a relaxed occasion with people eating at their own pace. Staff were seen to give people plenty of encouragement to eat independently and maintain skills. Saresta and Serenade DS0000017927.V341172.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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service receive very good personal and healthcare support that meets their needs. The home has systems in place to ensure the safe administration of medication and the protection of people living there. EVIDENCE: Care plans examined contain personal care guidelines with details of how people like to have personal care carried out. There is also information about communication so that people with complex needs can make their wishes understood by staff. Staff spoken with are able to demonstrate a good awareness of how people like to have their care needs met. There is evidence that care plans are updated to reflect people’s changing needs. Staff records examined show that staff induction includes awareness of the home’s policy and procedures around dignity and respect. During a discussion with the manager, she was able to demonstrate how the home works closely with relevant healthcare professionals to meet peoples individual healthcare needs. The AQAA states that due to the change of need for one person, all staff have received training on Gastrostomy tube feeding. A Saresta and Serenade DS0000017927.V341172.R01.S.doc Version 5.2 Page 15 sample of three care plans examined contains evidence of input from healthcare professionals including Community Nursing Services, G.P.s and the Learning Disabilities Outreach Team. The records also contain a wide range of information relating to the individual’s health, including seizure charts for monitoring epilepsy, weight charts and a nutritional profile. Information from the manager indicates that an epilepsy clinic is held at the home every six months; as a result of accurate recording of seizures and close liaison with the consultant and clinical nurse specialist for epilepsy, five people have been discharged within the past year because their epilepsy is well managed. None of the people living in the home have the capacity to self medicate. The homes procedures around the storage and administration of medication were checked. Care plans examined contain a profile of the individual’s prescribed medication. Medicine Administration Record (MAR) sheets were examined and found to be completed appropriately. The medication folder contains pictures of people living in the home together with their individual MAR sheet. Medication is stored securely in a locked cupboard. The manager confirmed that nine members of staff, including all senior and acting senior staff, have completed the open learning package for Managing & Safe Handling Medicines. Staff records examined confirm that this training has been carried out. Saresta and Serenade DS0000017927.V341172.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 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have access to an effective and understandable complaints procedure that ensures that they are listened to. The home operates robust practices and procedures to protect the people who live there. EVIDENCE: The home has an appropriate complaints policy in place. The AQAA states that no complaints have been received in the past twelve months and records examined confirm this. The manager has developed a recording sheet for both staff and relatives so that minor concerns can also be documented. A copy of this sheet is in every bedroom so that any minor concerns that arise can be documented promptly. As previously reported, the home has a range of policies in place to protect people living there, including an Adult Protection Policy and Procedure and a Whistleblowing Policy. Staff records examined all contain enhanced Criminal Record Bureau checks. Discussion with the manager and records examined indicate that staff receive training using the Essex Vulnerable Adults Protection Committee training pack and have received Protection of Vulnerable Adults (POVA) information booklets. Staff spoken with show an awareness of their responsibilities around responding to suspected abuse. Saresta and Serenade DS0000017927.V341172.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, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in Saresta & Serenade benefit from a homely, comfortable environment that is well maintained and clean. The home has adaptations and equipment that meets the needs of the people living there. EVIDENCE: A tour of the premises confirms that the home remains comfortable and homely. Furnishings are of good quality and the décor is bright and well maintained. In particular the standard of decoration in people’s bedrooms is very good and each room is decorated to reflect the individual’s taste. There is ample evidence of personal possessions and items relating to the individual’s interests. One person’s room has been fitted with an automatic door opener to ensure that they can access the room at any time without support. Another person is moving to a new room that will better meet their needs and at the time of the inspection was waiting to have a new carpet fitted. Saresta and Serenade DS0000017927.V341172.R01.S.doc Version 5.2 Page 18 People benefit from living in a well maintained home. Improvements include redecoration in some of the bedrooms, new cookers have been installed in both bungalows and maintenance work has been carried out to the plumbing in the utility room. At the time of the last inspection the bathroom in Saresta needed to be improved and the home had arranged for an Occupational Therapist to advise on improvements. The new bathroom has now been fitted and is a huge improvement. The room now has a Jacuzzi bath and overhead tracking and electric hoist. The room is very pleasant and people using it can now have an enjoyable bathing experience. Information provided in the AQAA indicates that all staff have now completed comprehensive training in infection control. The manager explained how these practices were essential when someone living in the home was found to have an infection on discharge from hospital. Good practices around infection control ensured the infection cleared up within a very short time. Staff records examined confirmed that this training has taken place and staff spoken with are aware of good practices around hygiene and infection control. As previously reported, the premises are clean and the laundry room contains appropriate flooring and equipment. Saresta and Serenade DS0000017927.V341172.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall people living in Saresta & Serenade benefit from a competent, well trained staff team, although they should continue to be supported to obtain relevant qualifications. The recruitment procedure in the home provides the safeguards that ensure appropriate staff are employed. EVIDENCE: As previously reported, staff continue to demonstrate a good awareness of people’s needs and are knowledgeable about their work. Evidence provided in the AQAA indicates that seven staff out of a total of 23 hold a National Vocational Qualification at level 2 or above. The manager said that a further five are working towards the award. Although staff are able to demonstrate that they are competent, in order to meet the National Minimum Standard of 50 of care staff with an NVQ, the home should continue to support and encourage staff to achieve the award. The home continues to operate an appropriate recruitment process to ensure people living in the home are protected. A sample of three staff files examined are well organised and all contain the required information including an Saresta and Serenade DS0000017927.V341172.R01.S.doc Version 5.2 Page 20 application form, a photograph of the member of staff, two written references and proof of ID. Files also contain a declaration of fitness to carry out the job signed by the member of staff. Evidence was also examined that Criminal Record Bureau (CRB) checks are carried out. As at the last inspection, the manager is able to demonstrate a good awareness of the CRB process and the Protection of Vulnerable Adults checks that are required to be completed for staff, which will help ensure service users are protected from abuse. Records examined contain evidence that staff receive appropriate induction training. There are also records of training in fire procedures, first aid, safety at work, manual handling, infection control, food hygiene, epilepsy awareness and administration of rectal diazepam. Staff spoken with are positive about training in the home. Since the last inspection there have been improvements in the process of supervising staff. The AQAA states that more staff meetings are now held and the minutes of the last staff meeting were examined. Records examined confirm the improvements in the supervision process. A sample of staff files examined contain supervision agreements and evidence that supervisions are being held regularly. All contain evidence of recent supervision. This improved process ensures that people living in the home benefit from being supported by a staff team who are themselves well supported. Saresta and Serenade DS0000017927.V341172.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 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in Saresta & Serenade benefit from a home that is managed by a competent person. The culture of the home ensures that interests of people living there are central to the way the home is run. The health and safety of individuals living and working in the home is promoted and protected. EVIDENCE: As previously reported, the manager has a City and Guilds Foundation in Management for Care qualification, but has not yet completed NVQ level 4 in care or the Registered Manager’s Award. She explained that there have been continuing difficulties with assessors but a new provider has been identified and funding is being sought. The manager identified in the AQAA that availability of NVQ training for manager is something the home could do better. Records examined and discussions on the day of the inspection confirm that the manager participates in other training with the staff team including Saresta and Serenade DS0000017927.V341172.R01.S.doc Version 5.2 Page 22 infection control and medication. In spite of the fact that she has not yet completed NVQ level 4 in management, observations show that the manager has developed her management skills and greatly improved procedures. Recording is much improved and also organisation within the home. The manager demonstrates excellent knowledge of the needs of people living in the home. She has built solid, supportive relationships with relatives and displayed sound staff management skills. Overall the home is well managed and the proprietors should continue to support the manager to develop her management skills and obtain further relevant qualifications to ensure service users benefit from a well run home. Observations of the way the home is managed, combined with information obtained from staff and relatives confirms that people living at Saresta and Serenade benefit from an open and positive atmosphere. The excellent approach to leadership and management ensures that the ethos of the home values person centred working practices. The homes Quality Assurance system has improved since the last inspection. The manager explained how the views of relatives are sought; relatives meetings take place and they get involved in decision-making. The quality assurance report from the previous year was examined and sets out how information obtained from staff questionnaires has been collated and action has been taken on the outcomes where improvement was needed; for example, the need for better communication was addressed by ensuring all staff are now included in handovers. Questionnaires from relatives were similarly collated and again an action plan is in place in response to feedback. A list of objectives that were identified for the coming year was examined. The home continues to have policies and procedures in place around safe working practices for the protection of people living there. Records examined confirm that checks have been carried out within the last 12 months on the fire alarm, electrical installation, portable appliance testing (PAT), emergency lighting and gas installation. Maintenance records also show that regular checks are carried out on water temperatures and fridge temperatures. Saresta and Serenade DS0000017927.V341172.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 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 3 27 X 28 3 29 4 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 4 3 X X 3 X Saresta and Serenade DS0000017927.V341172.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 YA32 Good Practice Recommendations The registered person should continue to pursue the availability of training courses so that more care staff may obtain NVQ qualifications. The registered providers should continue to support the manager to develop her skills and gain qualifications relevant to the management of the home. 2. YA37 Saresta and Serenade DS0000017927.V341172.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Saresta and Serenade DS0000017927.V341172.R01.S.doc Version 5.2 Page 26 - 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. 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