Inspection on 15/02/06 for Sea Gables

This inspection was carried out on 15th February 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 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sea Gables 07/03/07

Sea Gables 08/08/05

Sea Gables 20/01/05

Sea Gables 23/06/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Sea Gables 6 Northcliff Gardens Shanklin Isle Of Wight PO37 7ES Lead Inspector Annie Kentfield Unannounced Inspection 15th February 2006 11:00 Sea Gables DS0000012587.V250847.R01.S.doc Version 5.1 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 Sea Gables DS0000012587.V250847.R01.S.doc Version 5.1 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. Sea Gables DS0000012587.V250847.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Sea Gables Address 6 Northcliff Gardens Shanklin Isle Of Wight PO37 7ES 01983 861473 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 Anthony James Delannoy Hannah Louise Delannoy Mr Anthony James Delannoy Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Sea Gables DS0000012587.V250847.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th August 2005 Brief Description of the Service: Sea Gables is a three-storey house that has been converted to provide care and accommodation for six younger adults with a learning disability. All bedrooms are for single occupancy and have en-suite facilities. The home provides pleasant communal facilities and gardens. The home is located in a residential area of shanklin, close to shops and public transport. The home is jointly owned by Mr and Mrs Delannoy and managed by Mrs Delannoy who is in the home on a daily basis. Sea Gables DS0000012587.V250847.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second unannounced inspection of this inspection year; core and additional standards were assessed. The inspection was undertaken over two days. On the first day of the inspection the manager was not available and therefore a second inspector visited the home at a later prearranged date to complete the inspection and view staffing records only available with the manager present. The inspection lasted a total of four to five hours during which a tour of the building was undertaken. Discussions were held with staff on duty and everyone living at the home who was at the home during the inspection. Service users stated that they enjoyed living at the home and liked the staff. The relatives of two service users spoke with the inspector and confirmed that they were happy with the care their sons received. Care and other records and documentation identified in the report were viewed. What the service does well: What has improved since the last inspection? What they could do better: The home must ensure that pre-admission assessments are completed prior to any new people moving into the home. Sea Gables DS0000012587.V250847.R01.S.doc Version 5.1 Page 6 Care plans, individual guidelines, and risk assessments must be reviewed at least every six months and more frequent if needs change. All reviews must be dated and signed by the person completing the review. The home must ensure that the key for the medications storage cupboard does not open other cupboards within the home. It is strongly recommended that all care staff that dispense medication receive accredited training in the safe administration of medicines. Staff recruitment procedures must ensure that all information as specified in Schedule 2 and the Care Standards Act 2000 (Establishments and agencies) (Miscellaneous Amendments) Regulations 2004 are fully complied with. The home must complete a training needs audit and forward a copy of the planned training for the year 2006 to the Commission. The home must consider how service users’ involvement in quality assurance may be demonstrated. The manager must complete the Registered Manager’s award by October 2006. 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. Sea Gables DS0000012587.V250847.R01.S.doc Version 5.1 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 Sea Gables DS0000012587.V250847.R01.S.doc Version 5.1 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 The home must ensure that pre-admission assessments are completed on all people who may be admitted to the home to fully determine if their needs may be met at the home. EVIDENCE: The care plan for the person most recently admitted to the home was viewed and the inspector discussed the home’s admission procedures for another person admitted to the home since the previous inspection undertaken in August 2005. There was no evidence that a pre-admission assessment had been completed for the most recent admission to the home. The manager confirmed that the home had not completed an assessment for this person. The most recent admission to the home was known to the manager as he is a relative of another person already living at the home, however this would not mean that the home was aware of all his needs. The other person admitted to the home since the previous inspection was discussed with the manager. The manager stated that a pre-admission assessment had not been completed on this person who had been admitted from a social services respite unit where the placement could not continue. Even in situations where there is limited information the home must document their pre-admission assessment and identify that they are able to meet the potential resident’s needs. Sea Gables DS0000012587.V250847.R01.S.doc Version 5.1 Page 9 The home has a suitable pre-admission assessment format seen within another service user’s care plan who had been living at the home for about one year. This, or a similar format, must be used prior to any new people being admitted to the home. The pre-admission assessment is important to ensure that the home can meet the needs of the new person and that their needs are compatible with the existing people living at the home. Sea Gables DS0000012587.V250847.R01.S.doc Version 5.1 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 the following standard(s): 6, 7, 8 and 9. Everyone living at the home has a detailed individual care plan containing risk assessments and management guidelines that are designed to promote life opportunities and do not overly restrict people. The home must ensure that care plans, risk assessments and guidelines are reviewed at least every six months and additionally if care needs change. People who live at the home are provided with opportunities to make individual choices and decisions, however the home must consider how it will record and demonstrate residents’ participation in decision making in relation to the day-to-day running of the home. EVIDENCE: The care plans for two of the six people who live at the home were viewed and discussed with the manager and care staff. Care plans are detailed to meet individual needs and aspirations and cover social and health needs. Care plans were also seen to contain appropriate risk assessments designed to promote residents’ opportunities. Some of the people at the home may behave inappropriately and there are individual guidelines in place to support staff and residents should this occur. Recordings of inappropriate behaviours are Sea Gables DS0000012587.V250847.R01.S.doc Version 5.1 Page 11 appropriately maintained to monitor effectiveness of guidelines and influence decisions when care plans, risk assessments and guidelines are reviewed. Residents have signed a sheet at the front of care plans to indicate that they have been involved in the care planning process. The manager and care staff interviewed confirmed that the home operates a key worker system with all residents having a named key-worker. Whilst reviewing the care plans it was not evident when care plans had been reviewed. The home must ensure that care plans, risk assessments and guidelines are reviewed at least every six months and additionally if care needs change. Where possible residents should be involved in these reviews. The home has an appropriate policy and procedure for unexplained absences by residents with specific information and photographs held for all the people who live at the home. The inspectors were able to talk with a relative of two people who live at the home and with people who live at the home. They confirmed that people who live at the home are provided with opportunities to make decisions and choices about their lives and provided with opportunities to develop independence and life skills. The arrangements in respect of residents’ personal finances were not assessed. Discussions with the manager, care staff, relatives and people who live at the home indicated that residents are offered opportunities to participate in the day-to-day running of the home. The inspector discussed with the manager how these discussions, which are usually one-to-one as opposed to group discussions or meetings may be recorded and demonstrated. The manager is to consider this in line with quality assurance monitoring for the home. Sea Gables DS0000012587.V250847.R01.S.doc Version 5.1 Page 12 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): 11, 12, 13, 14, 16 and 17. The people who live at the home have individual weekly programmes of planned and ad-hoc activities both within the home and the local and Island community. A healthy varied diet is provided with residents participating in meal choices and preparation. EVIDENCE: The manager and staff are pro-active in supporting the residents to have happy and fulfilling lives with opportunities for a variety of social and leisure activities in addition to college and work. Care plans contained individual weekly plans for all residents. Discussions with care staff demonstrated that they are aware of individual residents’ likes and dislikes and actively seek to provide a varied and stimulating lifestyle. The relative of two people who live at the home confirmed that her sons had varied and active lifestyles doing things they liked to do and that opportunities were provided but the choice remained with the resident. The manager discussed holiday plans for residents. Last year all residents enjoyed a holiday in the New Forest. This was fully funded by the home. This Sea Gables DS0000012587.V250847.R01.S.doc Version 5.1 Page 13 year the home is to arrange a series of special days out which will enable residents to explore and enjoy the Island. It was evident that the routines in the home have a flexible and informal structure and meet the needs of residents. Each resident is supported to take responsibility for the cleaning and tidying of their bedroom. Both male and female staff of varied ages are employed by the home to support the male and female residents. The people who live at the home are involved in menu planning, food shopping and meal preparation. Health eating is encouraged with individual likes and dislikes being recorded in care plans. Residents stated that they liked the food at the home and could request alternatives to that offered. At the start of the second day of the inspection one resident was seen enjoying a late cooked breakfast. Residents have access to the kitchen at all times and can make themselves drinks and snacks if they wish. One resident has a special diet due to allergies and staff were clearly aware of what foods may contain ‘hidden’ things he should not have. Sea Gables DS0000012587.V250847.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Medication kept in the kitchen cupboard must be securely stored at all times and the cupboard must have its own lock and key. Care staff that dispense medication should have accredited training in the safe administration of medicines. EVIDENCE: Senior members of staff who have been trained by the manager dispense medication for residents in the home. However, it is recommended as good practice that care staff that dispense medication should have accredited training in the safe administration of medicines that must include basic knowledge of how medicines are used and how to recognise and deal with problems in use, and the principles behind all aspects of the home’s policy on medicines handling and records. The medication is stored in the kitchen and was in a locked cupboard, however, the member of staff explained that the same key also unlocks the cleaning cupboard and the manager was advised that all medication should be securely stored with a separate lock and key. The manager must demonstrate that medicines in the custody of the home are handled according to the requirements of the Medicines Act 1968, guidelines from the Royal Pharmaceutical Society of Great Britain and requirements of the Misuse of Drugs Act 1971. Sea Gables DS0000012587.V250847.R01.S.doc Version 5.1 Page 15 Records were inspected and show that a record is kept of current medication for each resident. However, it is recommended that the home has a clear policy on PRN medication that includes clear identification of PRN medication on the daily record sheets and a copy of individual requirements in the care plans. Sea Gables DS0000012587.V250847.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The people who live at the home are able to complain should they wish to do so. The home has appropriate adult protection policies and procedures, however training in adult protection should be provided for all staff who require this. The home must improve the recruitment procedures to ensure that unsuitable people do not work at the home. EVIDENCE: The home has a complaints policy which is made available to service users or their representatives in the service users’ guide. The complaints policy should ensure that all complaints are appropriately investigated within twenty-eight days. The home maintains a complaints book with no complaints having been received since the previous inspection in August 2005. Staff spoken with were aware of what procedure they should follow should a resident or their representative make a complaint. A relative spoken with during the second day of the inspection confirmed that she would discuss any concerns with the manager but that she had no concerns or complaints about the service her relatives received at the home. The people who live at the home are cognitively able to make a complaint and it is the inspector’s opinion that should they wish to do so service users are able to complain. Most of the people who live at the home attend college or day services and would be able to complain via these services if they wanted to do so. Service users spoken with stated that they did not have any concerns and were happy living at the home. The home has an adult protection policy which links to the Isle of Wight Adult Protection policy. The home has appropriate policies for whistle blowing and gifts to staff detailed in the staff handbook which was seen by the inspector. Sea Gables DS0000012587.V250847.R01.S.doc Version 5.1 Page 17 Discussions with the manager and staff showed that they had an understanding of adult protection issues, with the manager being clear about her responsibilities and actions that should be taken if abuse is suspected. The home always has a senior member of staff available on call when not in the home, the on-call list being seen during the inspection. Discussion with one member of care staff indicated that she was clear what might indicate abuse, she was less clear about the procedures that should be followed. The home must include adult protection training within the training programme 2006 so that care staff are clear about the procedures which should be followed. Whilst reviewing staff files it was not possible to identify POVA First and Enhanced CRBs undertaken by the home on the two must recently appointed members of care staff. CRBs were present for other care staff. These checks must be undertaken, and a clear POVA First check received prior to care staff commencing employment in the home. Whilst reviewing one staff recruitment file there was only one reference received with references from the previous employer, a care establishment, not having been received, the person having been working at the home for a number of months. The manager stated that she had a copy of the Care Standards Act 2000 (Establishments and Agencies)(Miscellaneous Amendments) Regulations 2004 amended regulations in respect of staff employment and these must be fully adhered to. All Schedule 2 information must be available for all people working at the care home. Sea Gables DS0000012587.V250847.R01.S.doc Version 5.1 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 the following standard(s): 24, 25, 26, 27, 28 and 30 The home provides a homely, comfortable and safe environment in a pleasant, well maintained property. EVIDENCE: During the inspection a tour of the communal areas and some bedrooms was undertaken. All areas of the home are well maintained, decorated to a high standard and contain all the appropriate furniture, fixtures and fittings. All bedrooms are for single occupancy and have en-suite facilities with residents having been involved in choices about decoration and fixtures. Bedrooms seen reflected the residents’ individual and personal tastes and choices. Residents’ individual timetables included support time for cleaning and tidying their bedrooms and undertaking personal laundry. The home has a spacious lounge/dining room and an additional sitting room that could be used for private visits or should people wish to have some quiet time other than in their own bedrooms. The kitchen is well equipped, spacious and has a dining area. A separate utility room is provided with equipment that meets the standards. Externally the home has a pleasant enclosed rear garden providing a patio area, lawn and flowerbeds. The home has two pet rabbits and a cat. Sea Gables DS0000012587.V250847.R01.S.doc Version 5.1 Page 19 The manager, care staff, visitors and residents stated that residents and staff respect their right to privacy and no one enters bedrooms without permission. The home is very clean, tidy and well maintained with a warm welcoming atmosphere. There is an office and separate sleep-in bedroom. Sea Gables DS0000012587.V250847.R01.S.doc Version 5.1 Page 20 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, 33, 34, 35 and 36. The home provides appropriate numbers of care staff to support the people who live at the home. The manager must undertake a full training audit and identify how training needs for the staff team will be met throughout 2006. A copy of the training plan must be forwarded to the Commission. The home must not allow any staff to commence employment until two references have been received and reasons why people have left previous care employment have been confirmed. The home must ensure that a clear POVA First check is received prior to any new staff commencing work at the home. EVIDENCE: The inspector spoke with staff members, relatives, residents and viewed staffing personnel files and duty rotas. Care staff stated that they enjoyed working at the home and felt supported by the home’s management team. Care staff were clear about their roles and responsibilities and motivated to provide new opportunities and experiences for residents. Observations of the interactions between care staff and service users during the inspection indicated that care staff treat service users with dignity and respect. The duty rotas for the month prior to the inspection and the month of the inspection were seen. A number of the people who live at the home have dedicated 1-1 support time and this is detailed on the duty rotas. Duty rotas Sea Gables DS0000012587.V250847.R01.S.doc Version 5.1 Page 21 indicated that appropriate numbers of care staff are available at the home. The manager stated and care staff confirmed that staff meetings occur. The minutes were not available, as the computer would not display this information. It is recommended that a hard copy be provided so that staff that have not been able to attend staff meetings can read what has been discussed and agreed. The home employs twelve care staff, four of which have at least NVQ level 2 in care. This equates to 33 of care staff having NVQ level 2 in care. The inspector saw a list on the office wall of care staff that are to commence NVQ level 2. This indicated that four further care staff have been identified to undertake NVQ level 2 training. A requirement is not made that the home must increase the numbers of NVQ level 2 qualified staff because the home is already taking action to achieve this. This will be reassessed during the next inspection. Some staff files seen contained certificates of training undertaken by care staff, others did not. A list of planned training for food hygiene, manual handling and first aid was seen in the office. This indicated that all staff undertake basic or refresher training in these subjects in the coming months. Discussions with the manager indicated that she had not undertaken a full training needs audit of all staff employed at the home. There were no plans to provide new staff with other mandatory training (fire awareness, health and safety, adult protection and medication for staff who administer medication) or service user specific training such as challenging behaviour. The manager must undertake a full training audit and identify how training needs for the staff team will be met throughout 2006. A copy of the training plan must be forwarded to the Commission. Both male and female staff of various ages are employed at the home and reflect the mixed gender of the people who live at the home. The manager confirmed that all care staff are over eighteen years old and only care staff aged over twenty-one years are left in charge of the home. The home’s recruitment procedures were discussed with the manager and the recruitment files were viewed. Applicants complete an application form and provide a full work history and the details for two written references. All files contained a completed application form. The file for a member of staff recruited since the previous inspection contained only one reference. There was evidence that references had been sought from the second referee, the previous employer was an NHS Trust care provider, however the person had commenced employment prior to the reference being received and this had not been rectified since the commencement of employment. Some staff files contained appropriate records of telephone references whilst waiting for written references to be received. The home must not allow any staff to commence employment until two references have been received and reasons why people have left previous care employment have been confirmed. The Sea Gables DS0000012587.V250847.R01.S.doc Version 5.1 Page 22 home has a full work history for care staff on the application form and must confirm why care staff have left previous care employment with the previous employer as per Department of Health POVA guidelines. The home undertakes Enhanced Criminal Record Bureau checks on staff employed in the home. The home did not have evidence that these had been sought for the most recently employed staff that had commenced work at the home. There was no evidence that POVA First checks had been undertaken on these staff prior to their commencing employment. This was discussed with the manager and joint proprietor. The home must ensure that a clear POVA First check is received prior to any new staff commencing work at the home. The manager and care staff confirmed that care staff receive both formal and informal supervision, with records of formal supervision and annual appraisals being held by the home, samples of which were seen during the inspection. Regular staff meetings are held during which staff are provided with information about changes within the home and issues affecting service users’ care are discussed. As previously recommended the home should provide hard copies of staff meeting minutes for staff not able to attend staff meetings. Duty rotas indicated that the manager works in the home five days per week and visits the home during evenings and weekends should the need arise and will work alongside care staff providing additional supervision and support. Sea Gables DS0000012587.V250847.R01.S.doc Version 5.1 Page 23 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, 38, 39, 41 and 42. The management arrangements are appropriate for the size of the home. The home has a warm, welcoming atmosphere with the proprietors regularly at the home. The manager must complete the NVQ level 4 in care and Registered Manager’s Award. The manager is to consider how these informal discussions can be documented and residents’ involvement in quality assurance demonstrated. Record keeping as identified earlier in the report must be improved. EVIDENCE: The home is jointly owned and managed by one of the proprietors who works at the home five days per week and frequently attends the home during evenings and weekends, living close to the home. The manager has not yet completed the NVQ level 4 in care and Registered Manager’s Award. The manager had previously indicated that this would be completed by January 2006. The manager must complete these qualifications by October 2006 and notify the Commission when this has been achieved. The manager must ensure that her own training needs are included in the training audit for the home. Sea Gables DS0000012587.V250847.R01.S.doc Version 5.1 Page 24 Both the proprietors were present for part of the inspection. They demonstrated a positive and open management approach and clearly have a good working relationship with the residents and staff. Care staff, visitors and the people who live at the home all stated that the proprietors were approachable and they could discuss any concerns with them. The proprietors have many years experience in the care sector with people with learning disabilities. They have a good knowledge of the various resources and services that are available in the local area. The inspector discussed quality assurance procedures with the manager. Due to the complex needs of the people who live at the home residents’ meetings would be inappropriate. The manager described how individually residents are asked about their views on specific aspects of the service such as new staff members. The manager is to consider how these informal discussions can be documented and residents’ involvement in quality assurance demonstrated. This standard will be reassessed during the next inspection. During the inspection a variety of records was inspected. These included preadmission assessments, care plans, risk assessments, support guidelines, medication administration records, staffing files and training records. As previously stated the home needs to ensure that pre-admission assessments are completed on all new people who are admitted to the home and that care plans, risk assessments and guidelines are dated and signed and reviewed at least every six months. The records in respect of staff recruitment must contain all the information specified in Schedule 2 and comply with the Care Standards Act 2000 (Establishments and Agencies)(Miscellaneous Amendments) Regulations 2004. Sea Gables DS0000012587.V250847.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 2 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 2 ENVIRONMENT Standard No Score 24 4 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 3 12 3 13 4 14 3 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X 2 4 2 X 2 3 X Sea Gables DS0000012587.V250847.R01.S.doc Version 5.1 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 YA2YA41 Regulation 14 (1)(a) (b)(c)(d) Requirement The home must ensure that a pre-admission assessment has been completed for all people admitted to the home, that prospective service users or their representatives are involved in the assessment and that it is confirmed in writing that the home is able to meet the service users’ needs. The home must ensure that care plans, risk assessments and management guidelines are reviewed at least every six months and if needs change. The manager must undertake a training needs audit and organise training as indicated by the audit. A copy of the training timetable for 2006 must be supplied to the Commission. Care staff cannot commence employment until two recorded references have been received. Telephone references must be followed up with written references. The Care Standards Act 2000 (Establishments and Agencies)(Miscellaneous DS0000012587.V250847.R01.S.doc Timescale for action 15/03/06 2. YA6YA9YA41 15 (2)(b) 01/04/06 3. YA32YA35 YA41 18 (1)(a) and (c) 01/04/06 4. YA34 YA41 19 (4)(b) and (c) 01/04/06 5. YA34 YA41 19 (1)(b) 01/04/06 Sea Gables Version 5.1 Page 27 6. YA31 10 (1) 7. YA39 YA41 24 (1), (2) and (3) 13(2) 8. YA20 Amendments) Regulations 2004 must be fully complied with. Care staff must not commence employment until a clear POVA first check has been received. The registered manager must complete the NVQ level 4 in care and Registered Manager’s Award by October 2006. A procedure must be implemented to demonstrate resident involvement in quality assurance. The registered manager must ensure that medicines received into the home are safely stored and administrated in line with the relevant regulatory requirements. 01/10/06 01/04/06 15/02/06 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 YA33 YA20 YA20 Good Practice Recommendations Hard copies of staff meeting minutes should be available for staff unable to attend meetings. The registered manager is strongly advised to ensure that all care staff that dispense medication receive accredited training in safe medication procedures. The registered manager must ensure that there is a clear policy on PRN medication and PRN medication should be clearly identified on the daily medication record sheets. Sea Gables DS0000012587.V250847.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight Ground Floor Mill Court Furrlongs Newport, IOW PO30 2AA 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 Sea Gables DS0000012587.V250847.R01.S.doc Version 5.1 Page 29 - 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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