Inspection on 24/05/06 for Saresta and Serenade

This inspection was carried out on 24th May 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Saresta and Serenade 22/05/07

Saresta and Serenade 12/10/05

Saresta and Serenade 04/05/05

Saresta and Serenade 30/11/04

Saresta and Serenade 19/05/04

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Sun Court Nursing Home

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Paradise Lodge

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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 Final Key Unannounced Inspection 24th May 2006 and 6th June 2006 09:30 Saresta and Serenade DS0000017927.V296757.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.V296757.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.V296757.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.V296757.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 12th October 2005 Date of last inspection Brief Description of the Service: Saresta and Serenade is a home providing care and accommodation for ten individuals with learning disabilities between the ages of 18 and 65, some of whom may have a physical disability. 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. Accommodation is provided in two separate bungalows, each offering single bedrooms for five individuals. Each bungalow has living accommodation, kitchen and its own laundry facilities. There is a small patio area situated between the two bungalows and a large garden area to the rear. Saresta and Serenade is situated in a small village close to local facilities. There are adequate parking facilities at the front of the bungalows for staff and visitors. 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 given to the Commission in April 2006. Saresta and Serenade DS0000017927.V296757.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A wide range of evidence was used to compile this report. The manager of Saresta & Serenade provided information in a pre-inspection questionnaire. Documentary evidence was examined, such as menus, staff rotas, care plans and staff files. Completed surveys were received from a sample of relatives of service users. A visit to the home took place on 24th May 2006 and, as the manager was away, the inspector was assisted by a senior carer and the General Manager. A second visit took place on 6th June 2006 when the manager was back. These visits included a tour of the premises, discussions with the manager and staff and observations of interactions between service users and members of staff. On both days of the inspector’s visit the atmosphere in the home was relaxed and welcoming and service users appeared happy. What the service does well: What has improved since the last inspection? The home has made some developments with its Quality Assurance (QA) system and surveys have been sent to relatives. However, this and other information collected as part of the QA system needs to be collated into a report that is made available to the Commission and other interested parties. The manager has made some improvements to the way minor concerns are documented and this should be developed further to ensure service users and their relatives are confident their views are listened to. Saresta and Serenade DS0000017927.V296757.R01.S.doc Version 5.2 Page 6 In addition to the information given to staff during the induction process, some staff have attended formal Protection of Vulnerable adults (PoVA) training. To ensure service users are protected from potential abuse, this programme should continue until all staff have received PoVA training. 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. Saresta and Serenade DS0000017927.V296757.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.V296757.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 at least once during a 12 month period. 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. There is a process in place to ensure prospective service users’ individual aspirations and needs are assessed. EVIDENCE: There have been no new service users for some time but the home has an appropriate assessment process. The information and evidence provided shows that the manager has a good awareness of assessment and the documentation around the process is appropriate. Saresta and Serenade DS0000017927.V296757.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs and goals are reflected in their Individual Plans. Service users are supported to make decisions about their lives. Service users are supported to take risks within the limitations of their capacity to understand. EVIDENCE: A sample of four service users’ records were examined on the day of the visit. The plans examined all identify the service user’s needs, the objectives of the plan, how care is to be carried out and what are the expected outcomes for the service user. Staff spoken with show that they have a good awareness of service users’ needs. Records examined have evidence of recent review of care plans and a member of staff confirmed that care plans are updated regularly and service users’ needs are re-assessed at least every three months. One service user whose needs have changed is going through a process of review that involves the G.P., physiotherapy services, the service user’s parents and the care management team. Saresta and Serenade DS0000017927.V296757.R01.S.doc Version 5.2 Page 10 There have been no new service users living at Saresta & Serenade since the last inspection visit. As reported at that time, no service users have the capacity to manage their own finances and all have appointees. Staff spoken with are able to demonstrate practical ways they help service users make choices, for example in choosing what to wear or what they want to eat. The inspector observed good interactions between service users and members of staff on the day of the inspection visit, staff spoke clearly and in friendly tones, made eye contact and waited for a response, such as change of facial expression. A senior member of staff was able to give information about communication and how staff support service users with little or no verbal skills to make choices. Records examined show that if there are limits to a service user’s ability to make choices it is documented in the care plan. Records examined at the inspection visit show that there are comprehensive risk assessments in place. At the last inspection visit the manager explained that, because of the service users complex learning disabilities, difficulties with communication and issues around the ability to make informed choices, relatives are consulted and involved in care planning and assessing risks. Saresta and Serenade DS0000017927.V296757.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are able to take part in a range of age, peer and culturally related activities and are part of the local community. Service users are supported to maintain appropriate relationships. The home ensures service users’ rights are protected. Service users are offered a varied and healthy diet that they enjoy. EVIDENCE: The complex physical needs and learning disabilities of the service users living at Saresta & Serenade means they are unable to participate in paid employment. However, the service supports service users to take part in a programme of activities and to access the local community. Daily records examined show that service users have meals out, go to the pub, go bowling and have hydrotherapy. On both visits by the inspector to the home, planned Saresta and Serenade DS0000017927.V296757.R01.S.doc Version 5.2 Page 12 activities outside the home were going on. Staff spoken with said that service users are supported to go shopping at a nearby supermarket. The manager and staff were able to demonstrate that family links are encouraged by the home and relatives visit regularly. Records examined show that relatives contact the home on a regular basis. Surveys have been sent to a sample of relatives by The Commission and at the time of compiling this report two responses have been received. Responses to surveys and comments received from relatives at the time of the previous inspection visit indicate an overall satisfaction with the home. Complex needs and communication difficulties makes it difficult for the inspector to ascertain verbally how service users view the service they receive. However, observations by the inspector on visits to the home indicate that service users appear relaxed and happy and that staff communicate well and make every effort to find out what service users want. One service user’s file examined shows that a “communication passport” is being developed to help staff better understand what the service user wants. Staff spoken with explained how they try to promote choice and independence through the daily routines. Three members of staff spoken with are interested, motivated and enthusiastic about their jobs and this contributes to the positive atmosphere in the service. Because of their complex needs, service users need support in varying degrees during mealtimes, ranging from support to cut up food to full assistance with feeding themselves. The lunchtime cooked meal on the day of the inspection visit was enjoyed by service users. Serenade operates a weekly menu, while Saresta uses a diary to record meals chosen on a daily basis by service users. A variety of fresh fruit and vegetables is available. Staff said that food is bought at local supermarkets and service users are involved in choosing foods that they like. Saresta and Serenade DS0000017927.V296757.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users preferences and requirements are taken into account when having personal support. The service ensures the physical and emotional health needs of service users are met. Service users are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Care plans examined all identify how care for individual service users is to be carried out. Staff spoken with said that care plans are updated regularly to reflect the changing needs and wishes of service users. Observations on the day of the inspector’s visits show that staff are aware of the need to ensure privacy is maintained when supporting service users with personal care. Staff records examined show that staff induction includes awareness of the home’s policy and procedures around dignity and respect. At the time of the last inspection visit, staff spoken with said that times for getting up and going to bed are flexible and mealtimes vary according to what service users are doing. Saresta and Serenade DS0000017927.V296757.R01.S.doc Version 5.2 Page 14 The home operates a key worker system to ensure service users have continuity of support. Service users’ records examined show evidence of G.P. appointments, and access to dentist, optician and chiropody treatment. Evidence was also seen of input from physiotherapists. There are guidelines for the administration of medication around seizures and recording charts are in place. The manager and staff spoken with have a good awareness of service users’ healthcare needs. There is an ongoing re-assessment of one service user whose needs are changing and there continues to be input from relevant healthcare professionals. There have been no changes to the group of service users living in the home since the last inspection visit and none are self-medicating. The home continues to operate a monitored dose system. The Medicines Administration Record (MAR) sheets were examined at this inspection visit. MAR sheets contain photographs of service users and appropriate information around the prescribed medications is in place. Medication administered is signed for appropriately. Saresta and Serenade DS0000017927.V296757.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall the views of service users and their representatives are listened to, although the home would benefit from more detailed records being kept of issues raised. The home ensures service users are protected from harm EVIDENCE: Records examined show that the home has a complaints policy in place. A pre-inspection questionnaire submitted to The Commission indicates that there have been no complaints during the last 12 months. At the last inspection visit it was noted that the home would benefit from more detailed records being kept of issues raised as concerns that are perceived as ‘minor’ had been dealt with in an informal way. The home has now introduced a feedback sheet for relatives that is left in service users’ rooms so that relatives can record any concerns they have whilst visiting. The manager said that this has been used on one occasion. Although this is an improvement on the previous informal way of dealing with concerns, the system could be further developed to show an audit trail from start to finish of how the concern was dealt with, the outcome and what changes have been made as a result. This will ensure that service users and their relatives can be confident that their views are listened to and acted upon. The home has a range of policies in place to protect service users from abuse, neglect and self-harm, including an Adult Protection Policy and Procedure and a Whistle Blowing Policy. Staff spoken with at the inspection visit show an Saresta and Serenade DS0000017927.V296757.R01.S.doc Version 5.2 Page 16 awareness of their responsibilities around responding to suspected abuse. All staff have had ‘in-house’ Protection of Vulnerable Adults (PoVA) training as part of the home’s induction process and have received Essex PoVA information booklets. There is also an ongoing programme of sending staff on PoVA training provided by the Primary Care Trust. Some staff has already completed this training and others are awaiting places as they become available. Saresta and Serenade DS0000017927.V296757.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a homely, comfortable and safe environment and their bedrooms promote their independence. Overall the home has the specialist equipment required to ensure service users’ independence is maximised, although the bathroom in one bungalow needs to be improved and updated. The home is clean and hygienic. EVIDENCE: On the day of the inspection visit, a tour of the premises was carried out. The home is bright, cheerful and furnishings are homely. Rooms are clean throughout the home and there are no offensive odours. Furniture in service users’ rooms is domestic in nature, although one service user has a bed with a padded surround that is not attractive. The home is in the process of finding something more appropriate that continues to meet the service user’s needs and an assessment has been carried out by a Saresta and Serenade DS0000017927.V296757.R01.S.doc Version 5.2 Page 18 physiotherapist. All service users’ rooms showed evidence of a variety of personal possessions such as televisions, hi-fis and sensory equipment. Bedrooms were decorated to reflect the taste of the individual service user. Although bedrooms do not have locks, none of the service users living in the home have the ability to use keys. One service user who, despite being mobile, is unable to open the bedroom door independently, is having an automatic ‘self-closure’ device fitted so that the door can be left open to enable the service user to access the room when wished, but the door will close automatically in the event of fire. Shared space in the home is of good size and comfortable. Both bungalows have large lounge/diners with domestic furnishings that are of good quality. The office doubles up as a sleep-in room for staff and has en-suite facilities. Records examined show that service users needs are assessed for any specialist equipment required. Hoists and other adaptations are available and appropriate maintenance records were examined. There are low level light switches throughout the home so that they can be reached easily by service users in wheelchairs. One service user has a standing frame. One of the bathrooms has recently been assessed by the Occupational Therapist with a view to installing a specialist bath. The current bath is domestic and used with a portable hoist. The bathroom itself is clean but the bath and fittings need to be replaced so that service users can have their needs met more comfortably and appropriately. The premises are clean and the laundry room contains appropriate flooring and equipment. All staff in the home are in the process of undergoing Infection Control Training through the Open Learning Network. Saresta and Serenade DS0000017927.V296757.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall service users are supported by competent staff, although further progress is needed around NVQ (National Vocational Qualification) training. Service users are protected by the home’s recruitment policy and procedures. Service user’s needs are met by appropriately trained staff. Service users will benefit if the staff supervision process is more robust. EVIDENCE: On the day of the visit the inspector observed that staff interacted well with service users. Staff spoken with are able to demonstrate a good awareness of service users’ needs, particularly around communication and choice. Staff show enthusiasm and are knowledgeable about the job. Information provided in a Pre-Inspection Questionnaire shows that 40 of care staff have completed NVQ at level 2 or above. One member of staff spoken with would like to do NVQ and the home supports and encourages staff, however there have been difficulties with the availability of places and assessors. Saresta and Serenade DS0000017927.V296757.R01.S.doc Version 5.2 Page 20 Staff records examined show there is an appropriate recruitment process in place. A sample of staff files examined show that there is relevant documentation in place, including application forms, two written references, and Criminal Records Bureau (CRB) checks. The manager is able to demonstrate a good awareness of the CRB and Protection of Vulnerable Adults checks that are required to be carried out for staff, which will help ensure service users are protected. Evidence provided by the manager in the Pre-Inspection Questionnaire shows that staff receive training around Fire Awareness, Food Hygiene, Infection Control, Health & Safety, First Aid and Epilepsy. This is confirmed by certificates for these courses seen in a sample of staff files examined. Staff spoken with think “training is good”. One member of staff spoken with demonstrated a good awareness of protection procedures. The inspector discussed an issue that was raised around inappropriate personal behaviour of one member of staff outside the workplace and how this had been managed. The manager had dealt with it informally with the member of staff involved, but is aware that these supervisory meetings should be better documented through a more structured supervision process. The manager has recently introduced supervision discussion sheets. There is evidence in the sample of staff files examined that staff have been receiving supervision approximately every two months. One member of staff has had supervision but it is “not regular”. Overall, although there is a staff supervision process in place, it needs to be more regular and structured to ensure service users are protected by well-supported and supervised staff. Saresta and Serenade DS0000017927.V296757.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall the home is well run, although the manager should continue to develop management skills and complete management qualifications. Service users views are taken into account, however the quality assurance system needs further development. The home ensures the health, safety and welfare of service users are promoted and protected. EVIDENCE: 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. The manager informed the inspector that she is not spending so much time in a ‘hands on’ role with service users and is now focusing her time on management duties. The manager should continue to Saresta and Serenade DS0000017927.V296757.R01.S.doc Version 5.2 Page 22 develop her management skills and obtain further relevant qualifications to ensure service users benefit from a well run home. Since the last visit some progress has been made with the home’s Quality Assurance programme. Surveys have been produced and sent to relatives and the manager is in the process of analysing and collating the information, although a final report has not yet been produced and made available to all stakeholders and other interested parties. The home has policies and procedures in place around safe working practices. The home has had a Fire Officer’s visit within the last year and recommendations implemented. Records are available showing that water temperatures and fridge temperatures are checked regularly and maintenance records show that fire equipment, emergency lighting, electrical wiring and hoists are in order and have been checked. Saresta and Serenade DS0000017927.V296757.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 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 2 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 2 X 2 X X 3 X Saresta and Serenade DS0000017927.V296757.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. 1. 2. Standard YA36 YA39 Regulation 18(2) 24(2) Requirement The registered manager must ensure that staff receive regular supervision. The registered manager must supply to the Commission a report in respect of the Quality Assurance review and make a copy of the report available to service users. Timescale for action 30/09/06 30/08/06 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. 2. 3. Refer to Standard YA22 YA23 YA29 Good Practice Recommendations The registered manager should continue to develop the complaints procedure, particularly around documenting concerns and the outcome. The registered manager should ensure that the programme of Protection of Vulnerable Adults training continues until all staff have attended. The registered person should ensure that plans to refurbish the bathroom and the provision of a specialist bath for service users with physical disabilities are taken forward. DS0000017927.V296757.R01.S.doc Version 5.2 Page 25 Saresta and Serenade 4. 5. YA32 YA37 The registered person should continue to pursue the availability of training courses so that more care staff may obtain NVQ qualifications. The registered manager should continue to develop her skills and gain qualifications relevant to the management of the home. Saresta and Serenade DS0000017927.V296757.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Saresta and Serenade DS0000017927.V296757.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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