Inspection on 14/09/05 for Sarsen House

This inspection was carried out on 14th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Sarsen House 21/11/06

Sarsen House 01/02/06

Sarsen House 16/03/05

Sarsen House 12/07/04

Sarsen House 26/02/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Sarsen House West Overton Marlborough Pewsey Wiltshire SN8 4ER Lead Inspector Tim Goadby Unannounced 14 September 2005 th 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 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 Stationary 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. Sarsen House D51_D01_S28644_SARSENHOUSE_v193088_050905_Stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Sarsen House Address 2 Inlands Close Pewsey Wiltshire SN8 1PS 01672 861139 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Tullyboy Homes Mrs Catherine Howie Care Home 6 Category(ies) of LD Learning Disability (6) registration, with number of places Sarsen House D51_D01_S28644_SARSENHOUSE_v193088_050905_Stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th March 2005 Brief Description of the Service: Sarsen House provides personal care and accommodation for 6 people with a learning disability. The service is owned by Tullyboy Homes, a private sector organisation. They run another similar home elsewhere in Wiltshire. Both owners have close involvement in all aspects of service delivery. Another senior staff member also participates in joint management of the two homes. The home is in the village of West Overton. This is approximately 3 miles from the town of Marlborough, which offers a range of amenities. The service first opened in 1995. Most of the service user group have lived at Sarsen House from that time. They also knew each other for many years beforehand. The property is a two storey house. A ground floor extension has been added since it became a care home. All service users have single bedrooms. Two of these have en-suite facilities. Others have access to bathroom and toilet facilities nearby. There is a range of communal space. The home also has a large garden. Sarsen House D51_D01_S28644_SARSENHOUSE_v193088_050905_Stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place in September 2005. It was a short notice announced inspection, arranged two days beforehand. The two homes operated by Tullyboy were both inspected on the same day. Findings have been applied to both services, where appropriate. The following inspection methods have been used in the production of this report: indirect observation; sampling of records, with case tracking; discussions with service users and management. What the service does well: What has improved since the last inspection? A restrictive practice is operated with one service user. Since the last inspection, this has been thoroughly reviewed, with multi agency involvement. Records have been substantially updated. There is now much clearer evidence that this sensitive practice is being properly monitored and evaluated. This provides greater reassurance that the welfare of the individual is being upheld, and that the practice, on balance, is in their best interests. Sarsen House D51_D01_S28644_SARSENHOUSE_v193088_050905_Stage4.doc Version 1.40 Page 6 The organisation’s risk assessment format includes a scoring system. Previously, this had not always been applied correctly. But the examples seen during this inspection were completed accurately. 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. Sarsen House D51_D01_S28644_SARSENHOUSE_v193088_050905_Stage4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Sarsen House D51_D01_S28644_SARSENHOUSE_v193088_050905_Stage4.doc Version 1.40 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 standard(s) 1, 2, 3, 4 & 5 Prospective service users have the necessary information to make a choice about the home. Prospective service users have their needs assessed, and are able to undertake trial visits to the home. Service users have their needs and aspirations met by the home. Service users have individual terms and conditions of residence in the home. EVIDENCE: The home has produced all required documentation about its services and facilities in thorough detail. It has also made some available in adapted formats that residents might understand. All the necessary criteria are addressed. Information is presented in a clear and easily understandable form. Most of the current service users have lived at Sarsen House since it first opened. They also knew each other for many years beforehand. As a well established group, they appear settled and happy. The service has developed a strong knowledge of their needs. There is also a focus on continuing to promote new opportunities and experiences. The Tullyboy staff team bring Sarsen House D51_D01_S28644_SARSENHOUSE_v193088_050905_Stage4.doc Version 1.40 Page 9 various areas of expertise. Support is also accessed from a range of other professionals and agencies. The needs of the service users are changing over time. This is mainly due to the ageing process. This can affect people with learning disability earlier in life than for the general population. Both physical and mental health may be affected. Sarsen House is adapting to meet these changing needs as far as possible. For instance, staffing is being kept at three per day to reflect the higher support required by some individuals. There is also a recognition that further resources may be needed in future. The service is liaising with relevant agencies to keep them updated about the way people’s needs are developing. There had been one new admission to the home, which took place in August 2005. Records showed that there had been a detailed pre-admission assessment process. The format used covers a wide range of possible need areas. Any which are highlighted as relevant are then picked up, and explored in more depth. Assessment had involved getting the views of the prospective service user themselves, as well as gathering information from all other possible sources. The new service user had undertaken some introductory visits to Sarsen House, including one overnight stay. This had enabled their compatibility with the existing group to also be considered. A meeting of relevant persons had taken place before admission, to consider the decision about placement. Initial review of the move had taken place after a month. This had concluded that Sarsen House appeared to be meeting the individual’s needs well. Already they appeared calmer and more stable than they had been in their previous setting. Further review was set to take place after three months. Service users’ contracts reflect that their places are funded by the local authority. Updated information is available to show fee levels for the current year. The home has produced its own information on key terms and conditions of residence. Sarsen House D51_D01_S28644_SARSENHOUSE_v193088_050905_Stage4.doc Version 1.40 Page 10 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 standard(s) 6, 7 & 9 Service users have their abilities, needs and goals reflected in their individual plans. Service users can make choices and decisions in their daily lives. Service users are supported to take positive risks and access new opportunities, as part of an independent lifestyle. Restrictions on service users are kept under regular review, with the involvement of all relevant persons, to enhance the protection of the individual. Records need to be kept updated as part of this process. EVIDENCE: Sarsen House D51_D01_S28644_SARSENHOUSE_v193088_050905_Stage4.doc Version 1.40 Page 11 The home has a comprehensive care plan format. This provides a range of relevant information for each user. Needs are identified. The actions to be taken in response are clearly described. There is also a focus on people’s strengths and preferences. The home’s practice under a range of standards can be seen by reference to these plans. Care plans include a section on goals for each individual. These set out the actions being taken towards these targets. They provide a framework for review. This takes place at regular intervals. Where changes have been made, the previous information is also left visible. This shows how things have developed. A full care plan was already in place for the newest service user. It was seen this was gradually being reviewed and updated, as the individual settled in, and more information became available. Some issues were presenting differently to the way initial assessment had suggested. Records were being amended accordingly. The home’s approach had been to allow the person to express themselves naturally, and to respond to this. The home promotes people’s rights to make their own choices and decisions, wherever possible. A Users’ Charter sets out their entitlements. Experimentation and exploration are encouraged. The input of the home’s staff team, and other relevant parties, is to ensure that responsible decisions are reached by a process of assessment. Guidelines for the approach taken to particular needs are drawn up with help from other professionals. Systems for the management of service users’ money appear to be efficient. The registered manager acts as corporate appointee. Appropriate recording is in place to demonstrate the home’s accounting systems. These are open for inspection, if relatives wish it. They are also checked annually by an external accountant. Arrangements for direct payment of service users’ benefits income are in line with guidance set out by the CSCI. The account used for this purpose is kept separate from the main business account of the home, not forming part of its assets. Also, the account records are itemised, to show separately deposits and withdrawals for each individual service user for whom monies are received. A range of risk assessments are in place. They are kept under review. They include topics specific to individual residents. Guidelines for particular areas are drawn up with input from relevant professionals. This is shown clearly on the record. A particular restrictive practice is operated with one service user. Care standards legislation allow the possibility of such an approach, if it is the only practicable means of securing the individual’s welfare. Since the previous Sarsen House D51_D01_S28644_SARSENHOUSE_v193088_050905_Stage4.doc Version 1.40 Page 12 inspection there has been extensive review and consultation around this issue. The individual’s care record now contains far more supporting information about the use of the technique. Decision making has been shared, to enhance the protection of the vulnerable individual. It is clear that it is being kept under regular review. Some further updating is needed within relevant records, to ensure that all the most current information is clearly and coherently presented. The care plan was last amended in May 2005, and there have been further key developments since that point. In particular, the guidelines agreed in June 2005 need amending, to accurately reflect the current pattern of usage of the practice, which is much higher than they suggest. Some earlier guidelines which remain on file could now be archived, to minimise any possible confusion. Sarsen House D51_D01_S28644_SARSENHOUSE_v193088_050905_Stage4.doc Version 1.40 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 & 16 Service users are provided with a range of activities and opportunities, offering them full engagement with their local community. Service users are able to maintain and develop appropriate relationships with family and friends. Service users’ rights and responsibilities are upheld, balanced with appropriate steps to safeguard their welfare. EVIDENCE: Sarsen House D51_D01_S28644_SARSENHOUSE_v193088_050905_Stage4.doc Version 1.40 Page 14 Service users attend various educational and occupational activities during the week. Staff from the home may support some of these sessions. People also receive support on an ‘outreach’ basis. This enables them to have opportunities at home, or in the community. Sessions which take place at Sarsen House provide a chance to join in for those service users who are too unwell to go elsewhere. When service users have gaps from either of these options, the home’s own staff offer one to one support. Work was especially being focused on the newest service user, to ensure that they had a full and active programme, whilst more sessions at other facilities were being pursued. There is a strong focus on ensuring that service users participate in their local community. The group have become well known within the village itself. Some friendships have been established with local people. Several service users regularly attend the village church. All users have access to a wide range of activities. This is both at home, and outside. At home, people have entertainment equipment in their own rooms, as well as in communal areas. There are also a range of games, puzzles, and books available. Outside the home, users attend some local clubs specifically intended for people with learning disability. They also access a full range of integrated activities. Usually people will go out either individually or in pairs, accompanied by staff. It is clear that this is seen as an important aspect of service delivery. All users receive the opportunity of an annual holiday, escorted by staff. These are done in small groups. Some people may only go for short breaks, if they find it difficult to cope with longer periods of absence from familiar surroundings. Holiday destinations have included trips overseas. Two service users were away for a short break when this inspection took place. There are no restrictions on visiting times. Service users can see visitors in their own room, the small sitting room, or in the garden. Sarsen House supports all its residents in maintaining contact with friends and family. As well as visits, this may be done by letters and phone calls. Relatives are seen as a valuable resource. They can provide knowledge about the needs and life history of individual users. Interaction between service users and staff is positive and relaxed. People are able to choose how they spend their time when at home. Staff are knowledgeable about individuals, and sensitive in respecting their wishes. Sarsen House D51_D01_S28644_SARSENHOUSE_v193088_050905_Stage4.doc Version 1.40 Page 15 The home operates a no smoking policy. There is generally unrestricted freedom of movement for residents. They are expected to respect the privacy of each person’s own bedroom. Some areas are kept locked for particular health and safety reasons. External access is also made secure. Sarsen House D51_D01_S28644_SARSENHOUSE_v193088_050905_Stage4.doc Version 1.40 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 & 19 Service users are supported to address their personal and health care needs effectively. EVIDENCE: All the people living at Sarsen House have assistance with personal care. This is tailored individually, depending on their abilities, and any safety concerns. For instance, some people may require observation when bathing, due to their health needs. Attention is given to ensuring that residents maintain a positive image at all times. Health needs continue to develop for the group. These may be linked to natural ageing processes, or to the particular conditions that people have. There is ongoing monitoring and review of care. As well as responding to situations as they arise, the home plans ahead for likely future changes. This includes ensuring that staff receive training on any relevant topics. As particular individuals have become seriously unwell, additional support has been accessed from all relevant health professionals. Getting input from a range of appropriate sources has been beneficial to both service users, and to the staff team at Sarsen House, by providing skilled assistance, and reassurance that all possible steps are being taken. Sarsen House D51_D01_S28644_SARSENHOUSE_v193088_050905_Stage4.doc Version 1.40 Page 17 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 standard(s) 22 & 23 Service users are safeguarded by the home’s policies and procedures for complaints and protection. EVIDENCE: A complaints procedure is in place. There is a version with symbols and photographs, intended to be more comprehensible for service users. No complaints had been received. Sarsen House operates in accordance with local multi-agency arrangements for adult protection. A copy of the relevant procedure is kept in the home. A whistle blowing policy is also in place. The home has appropriate staff conduct and disciplinary procedures. Potential disturbed behaviour from service users is addressed clearly in their care plans. There are appropriate guidelines for staff on how to manage any such situation. Sarsen House D51_D01_S28644_SARSENHOUSE_v193088_050905_Stage4.doc Version 1.40 Page 18 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 standard(s) 24 Service users live in a comfortable, clean and safe environment, suitable to their needs. EVIDENCE: Sarsen House is an attractive property, set in its own garden, in a pleasant village location. Accommodation for service users is provided on two floors. This includes a ground floor extension that was added by Tullyboy. The home presents as well decorated and maintained. There is an ongoing programme for this. Since the previous inspection, the property had been completely rewired. New oil tanks had also been installed. Some areas of paintwork had been renewed. Most major work is carried out whilst service users are away on holiday. Sarsen House D51_D01_S28644_SARSENHOUSE_v193088_050905_Stage4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34, 35 & 36 Service users are supported by suitable numbers of appropriately trained staff. Service users are protected by effective recruitment practices. Staff are supported and supervised effectively, enabling them to deliver a service that meets its users’ needs. EVIDENCE: Sarsen House D51_D01_S28644_SARSENHOUSE_v193088_050905_Stage4.doc Version 1.40 Page 20 As a service registered under previous care home legislation, Sarsen House must maintain minimum staffing levels in line with those in place as of 31st March 2002. Staffing requirements are being kept under review, as the needs of service users develop. The home has a minimum of two staff on duty during daytime hours, but aims for three or even four when possible. This is because one service user may need two staff to support their needs at any time. So a third person is required, to attend to the needs of other service users, and be able to escort people away from the home. Managerial staff are usually present during daytime hours, and form part of the numbers providing care. Nights are now covered by waking staff, due to the increased support needs of some service users. Three people are employed to work night duty The home was fully staffed at the time of this inspection. When necessary, cover is maintained by a pool of relief staff. On occasions, agency staff have also been used. The home employs one person aged under 18, for some cleaning duties. This person also assists with taking service users out. They are always supervised by other staff, and do not deliver any personal care. There is a checklist for all stages of recruitment, selection, and joining the organisation. This is closely linked to the home’s quality assurance system. Sampled records showed that all required checks are carried out, at the appropriate times. New starters do not commence working until satisfactory clearances have been obtained. Service users have informal involvement in the recruitment and selection of staff, as candidates visit the home. All new starters are subject to an initial probationary period of 6 months. This may be extended, if it is felt that an employee has not yet demonstrated the necessary competence or conduct. Additional supervision arrangements are then put in place. On initial induction, staff will be overseen by a manager for the first fortnight. They will then be supervised by a senior carer. The home’s training programme looks to access any courses which may be relevant to the needs of the user group. Some learning also takes place in-house. Talks are occasionally given by some of the professionals with whom the home has contact. Individual training records are maintained for all employees. These include information about any qualifications people may have gained in previous employment. Sarsen House D51_D01_S28644_SARSENHOUSE_v193088_050905_Stage4.doc Version 1.40 Page 21 Induction of new employees is carried out in line with national standards for people working in learning disability services. One of the organisation’s managers acts as an assessor of employees working in other homes. This helps Tullyboy to earn credits towards putting its own candidates through the training. The organisation also has a strong commitment to NVQ training. At Sarsen House, two carers have achieved the Level 2 award. Both, along with another colleague, are now due to study for Level 3. Another three carers have already achieved this higher award. All staff receive supervision and appraisal, including those who only work a few hours a week. Both of the organisation’s registered managers act as supervisors for a group of staff. Ways were being considered in which to record more of the informal supervision that takes place as they work alongside people. Staff meetings are held regularly, and these are used in part as group supervision sessions. For instance, policies and procedures can be presented and discussed. Sarsen House D51_D01_S28644_SARSENHOUSE_v193088_050905_Stage4.doc Version 1.40 Page 22 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 41, 42 & 43 Service users benefit from a well run home, with clear leadership and involvement from senior figures. Quality assurance measures underpin service developments. Effective record keeping is maintained, upholding service users’ best interests. Service users’ health and safety are protected by the systems in place. EVIDENCE: Sarsen House D51_D01_S28644_SARSENHOUSE_v193088_050905_Stage4.doc Version 1.40 Page 23 Tullyboy Homes has two registered managers. Both work in both of the homes operated by the organisation. They are each qualified to the required levels in both care and management. In addition, one has a professional background in learning disability nursing. Although not practising in this setting, she has maintained her registration through regularly updating her knowledge. The managers attend a range of courses and conferences. Tullyboy Homes is also a member of organisations concerned with developments in the social care field. Usually these two senior staff will alternate the weeks when they focus on Sarsen House. The other week will be spent in the organisation’s other care home. However, they are available for advice and support when required. The access to two well qualified managerial staff is of advantage to the service. One carer within the organisation is now studying towards the NVQ Level 4 award, and taking on additional responsibilities. The intention is that this person will also be able to offer managerial support to both services. An extensive quality assurance system has been devised and implemented by the organisation. It is built around the home’s Statement of Purpose, and tailored specifically to the service. The system enables a comprehensive audit of all areas of performance. Frequencies of review are set at varying intervals: monthly, quarterly, or annually. Staff are allocated different areas to check. Annual review is tied in with the service’s end of financial year. This enables findings to be incorporated into the next year’s business plan. It is also shown who is responsible for checking on various areas. Views of service users have been accessed via a questionnaire exercise. Sarsen House maintains all required areas of recording. The home’s record keeping policy reflects the requirements of the Data Protection Act. It makes clear the rights of access of users to the records held about them. There is evidence of regular checks and maintenance on key equipment and systems. The home’s central heating boiler was being serviced on the day of the inspection. Policies and procedures are in place for a range of relevant issues. Risk assessments have been carried out, and are kept under review. Staff receive regular training on health and safety topics. This is updated as necessary. The fire log book showed that the prescribed checks, practices and staff instruction are recorded as being carried out and up to date. The property’s fire risk assessment was reviewed in June 2005. Sarsen House D51_D01_S28644_SARSENHOUSE_v193088_050905_Stage4.doc Version 1.40 Page 24 Business and financial planning arrangements for the service were viewed and discussed during this inspection visit. All appear to be appropriate. Accounts are certified annually. Relevant insurance covers are in place as required. Sarsen House D51_D01_S28644_SARSENHOUSE_v193088_050905_Stage4.doc Version 1.40 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 x Standard No 31 32 33 34 35 36 Score x 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sarsen House Score 3 4 x x Standard No 37 38 39 40 41 42 43 Score 4 x 3 x 3 3 3 D51_D01_S28644_SARSENHOUSE_v193088_050905_Stage4.doc Version 1.40 Page 26 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 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 YA7 Good Practice Recommendations Information in care records, about the restrictive practice operated in respect of one service user, should be updated further, and presented more clearly. Sarsen House D51_D01_S28644_SARSENHOUSE_v193088_050905_Stage4.doc Version 1.40 Page 27 Commission for Social Care Inspection Avonbridge House Bath Road Chippenham Wiltshire SN15 2BB 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 Sarsen House D51_D01_S28644_SARSENHOUSE_v193088_050905_Stage4.doc Version 1.40 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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