CARE HOME ADULTS 18-65
Sea Gables 6 Northcliff Gardens Shanklin Isle Of Wight PO37 7ES Lead Inspector
Liz Normanton Key Unannounced Inspection 7th March 2007 09:30 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.V327207.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. Sea Gables DS0000012587.V327207.R01.S.doc Version 5.2 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 Hannah Louise Delannoy Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Sea Gables DS0000012587.V327207.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 15th February 2006 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. Weekly Fees: £419.91 plus additional charges for one to one care package. Sea Gables DS0000012587.V327207.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken on 07/03/07 and focussed on what the Commission considers to be core standards for a care home for younger adults as defined in the Department of Health (DOH) National Minimum Standards. We also looked for evidence of the homes compliance with requirements made at the last inspection. Information was gathered from a variety of sources, which included data being sent to the Commission prior to the site visit, discussion with one service user, written feedback from five service users, feedback from three relatives, discussion with one staff and the manager. Two staff files and two service users’ files were also viewed. This information was then triangulated to access outcomes for people living at the home. There was evidence that the home had complied with previous requirements except one which was with regard to the manager having to completed, the National Vocational Qualification (NVQ) level 4 and Registered Managers Award (RMA). The inspector was satisfied that the above will be completed before the end of 2007 and therefore a further requirement was not made. The overall outcome was that the residents and relatives are very satisfied with the service provided at the home. One requirement and three good practice recommendations have been made at this inspection. What the service does well:
The people who live at the home are all treated as individuals and actively supported by the manager and staff to be as independent as possible with each having a busy timetable of planned and ad-hoc activities. The home is very comfortably furnished and well decorated to a modern standard with two lounges and a pleasant enclosed rear garden. The home has a pleasant, friendly atmosphere with relatives and friends welcome to visit at all reasonable times. The home is well managed and the manager and staff promote residents diverse needs. Sea Gables DS0000012587.V327207.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sea Gables DS0000012587.V327207.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 Sea Gables DS0000012587.V327207.R01.S.doc Version 5.2 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has the tools to undertake a needs assessment and has done so in the past. At the last inspection the home had failed to meet this requirement, however the manager is aware of the oversight therefore prospective residents can expect the home to assess their needs prior to offering them a placement. EVIDENCE: At the last inspection a requirement was made that the home must complete a needs assessment prior to offering prospective residents a placement. In discussion with the manager they reported that there have been no new admissions since the last inspection. The manager also reported that they would ensure to undertake a needs assessment in future. We were sent a copy of the homes needs assessment document and we have in the past been satisfied that the home has completed needs assessments on individuals prior to admission. We can conclude from this that there was an over sight noted at the last inspection and that in the future the home will not admit prospective residents until having assessed whether the home can meet an individuals needs. Sea Gables DS0000012587.V327207.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Each resident 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 reviews care plans and risk assessments on a regular basis and additionally if care needs change. People who live at the home are provided with opportunities to make individual choices and decisions. EVIDENCE: We looked at two residents support plans and found them to contain all the necessary details required to enable staff to support people in the way they required and wished. The home is using a person centred approach in support planning but may want to consider writing up the care plan in the first person which they are not currently doing.
Sea Gables DS0000012587.V327207.R01.S.doc Version 5.2 Page 10 Support plans had been produced in a picture format, which should be understood by residents. In discussion with a member of staff they reported that staff are responsible for the reviewing of the care plans and this is done with each resident on a weekly basis and key workers review them on a monthly basis. There was evidence on care plans that they are being reviewed. Residents are promoted to make decisions and there was evidence seen on files that the home had arranged for two residents to have independent advocates so that they can discuss plans for their future. In written feedback from five residents they informed us that they are able to make decisions about how they wish to live their lives. In discussion with one member of staff they reported that residents are able to make choices. There was evidence on resident’s files that the home undertakes comprehensive risk assessments and takes action to minimise risks. Resident’s are encouraged to take risks as part of an independent lifestyle and in developing independent living skills. In feedback provided in 3 returned relative comment cards two parents felt they were consulted about their relatives care and where kept informed about important matters affecting their relative whilst one felt that they were not always involved. Sea Gables DS0000012587.V327207.R01.S.doc Version 5.2 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are supported to attend day centre services, college and employment. The home is situated close to local amenities and residents are part of the local community. The daily routines of the home promote independence, individual choice and freedom of movement. The residents are involved with menu planning and have access to a varied, nutrional and healthy diet. 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. In discussion with a member of staff
Sea Gables DS0000012587.V327207.R01.S.doc Version 5.2 Page 12 they reported that two additional staff were on duty and were out supporting one resident in their employment. Care plans contained individual weekly plans for all residents. In discussion with care staff they demonstrated that they are aware of individual residents’ likes and dislikes and actively seek to provide a varied and stimulating lifestyle. In discussion with one resident they said, “I go to college twice a week and attend swimming club, special Olympics, church and ten pin bowling.” They were also looking forward to going to London to see a show with a relative. In discussion with one member of staff they reported that last year the home arranged for residents to have special days out exploring and getting to know the Island. They understood there were plans for residents to go to Sandy Balls this year on the mainland. They also reported that some residents go away on holiday with their families in addition to having a holiday organised by the home. The home ensures that residents are fully integrated within the local community; people are supported to use public transport, attend college and work, and visit local shops, hairdressers, cafes, and pubs. In discussion with the manager they reported that the home has a vehicle to take residents out into the community and to attend appointments. Two female residents have been supported to develop personal relationships with the home providing the opportunities their boyfriends to stay overnight. One resident showed us their engagement ring and photographs of their boyfriend. Risk assessments have been completed with respect to the overnight stays. Residents are supported to maintain links with their families and in discussion with a member of staff they reported that several of the residents go to visit their parents. One resident said, “I go to my mums on a Saturday and stay over night and I go to the pub with my brothers on a Friday”. 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. All bedrooms are fitted with locks and in discussion with the manager they reported that all residents have been given keys but prefer to leave their doors unlocked. Interaction between the staff member on duty and the one resident at home was observed to be very positive, with staff demonstrating a calm and relaxed approach when the resident was showing signs of anxiety.
Sea Gables DS0000012587.V327207.R01.S.doc Version 5.2 Page 13 The manager and member of staff reported that residents are involved in menu planning, food shopping and meal preparation. Healthy eating is encouraged with individual likes and dislikes being recorded in care plans. No comments were made about food in the five returned questionnaires. Only one resident was at home and did not make a comment about the food, however we know from past inspections that residents have been happy with the meals provided at the home and are able to request alternatives if they do not like what has been prepared. Residents have access to the kitchen at all times and can make themselves drinks and snacks if they wish. One resident was observed doing their own laundry and generally pottering around the kitchen engaged in independent living skills. Sea Gables DS0000012587.V327207.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents personal support requirements are documented and understood by staff. The home promotes residents health care but is advised to arrange annual health checks, especially for those that are in good health and do not have reilar contact with their GP. The home has complied with the requirements of the last inspection in respect to medication procedures however there is still room for improvement in this area with staff needing to ensure that they sign when medication is taken or refused. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information was written in to care plans about the way people prefer to have personal support. Sea Gables DS0000012587.V327207.R01.S.doc Version 5.2 Page 15 Personal support is provided in the privacy of residents’ rooms, which are all fitted with a shower cubicle. Residents are able to express their individuality and one resident was seen sporting a funky Mohican hairstyle. In discussion with a member of staff they reported that residents choose their own style of clothing, hairstyle etc. Residents are supported to express their sexuality. In discussion with the manager they reported that they were not aware that any of the residents were homosexual or Lesbian but believed that the home could support people’s individual sexuality. Each Resident has a Health Action Plan as part of their care plan. All residents are registered with a general practioner (GP). The staff team support residents to access medical appointments. There was evidence in health care plans that residents have eye tests and access to dental treatment. In discussion with the manager they reported that residents get medical attention as required and do not have annual health checks. The home would be advised to arrange annual health checks for residents with their consent. The requirement from the last inspection to have a separate lock fitted to the drugs store has been complied with. In discussion with a member of staff they confirmed that they had undertaken medication training at the Isle of Wight College in addition to having had in house training. The home has a record of medication being received by the pharmacy and medication returned to the pharmacy. Medication is ordered monthly and is dispensed by the pharmacist in to blister packs to prevent the risk of errors. The home keeps records of medication administered by staff which had been completed as a general procedure however there were a small number of omissions of signatures on the medication administration records (MAR) sheets which included medicines given on the morning of the inspection, this was discussed with the manager who checked the blister packs and found the medication had been given but was unsigned. The manager agreed to discuss this with the persons responsible. Details of non-prescribed drugs are in residents’ care plans and separate record sheets are kept when these are given. The home does not have any controlled drugs in store. Sea Gables DS0000012587.V327207.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure and are protected from abuse and have their rights protected. EVIDENCE: The homes service users’ guide has a complaints policy which is made available to service users and/or their representatives. The home maintains a complaints book with no complaints having been received since the last inspection in January 2006. In discussion with one member of staff they were able to demonstrate that they were aware of what procedure they should follow should a resident or their representative make a complaint. In returned comment cards from three relatives two informed us that they know how to make a complaint but have not done so because they are happy with the service. One informed us that they had no knowledge of the complaints procedure but have made a complaint. 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. Five residents returned questionnaires and informed the commission that they had information available to them, which told them how to make a complaint. Sea Gables DS0000012587.V327207.R01.S.doc Version 5.2 Page 17 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. 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, and was clear about the procedures that should be followed. There was evidence that the manager had complied with the requirement in respect of safeguarding residents when recruiting staff this is detailed in the outcome area for staffing. Sea Gables DS0000012587.V327207.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables residents to live in a safe, well–maintained and comfortable environment, which encourages independence. EVIDENCE: A full tour of the home was undertaken which included all communal areas and every bedroom. We found that the home continues to be well maintained, is decorated to a high standard and contains all the appropriate furniture, fixtures and fittings as required under the national minimum standards. All bedrooms are for single occupancy and have en-suite facilities and residents having been involved in choosing the decoration and fixtures. All Bedrooms seen reflected the residents’ individual and personal tastes and choices.
Sea Gables DS0000012587.V327207.R01.S.doc Version 5.2 Page 19 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. In the lounge there was evidence that there had been a water leak with ceiling plaster having to have been removed, although this looked unsightly there was no adverse effects caused to the residents and the area had been cordoned off with the creative layout of the furniture to prevent residents going in to the area. In discussion with the manager they reported that the home had purchased two leather settees for the lounge, a new kitchen table, a tumble drier and washing machine since the last inspection. The kitchen is well equipped, spacious and has a dining area. We noted that the home were using cotton hand towels in the kitchen to use after hand washing, communal use of hand towels can lead to the potential risk of infection being spread and the home should consider how best to prevent this from happening. 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. There is a small area of garden to the front of the house, which was well tended. The balcony area outside the sitting room is used as a smoking area for staff and a plant pot filled with sand had been provided to stub out cigarettes however this was full and looked unsightly. 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.V327207.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home, are trained and skilled to meet the support needs of the residents. There has been an improvement in the homes recruitment procedures, which have become more robust to ensure the safety of residents . EVIDENCE: At the last inspection 3 requirements were made that the home improve its recruitment procedures to ensure the welfare of residents was safeguarded. We looked at two staff files of staff employed since the last inspection in January 2006 and the files contained all the appropriate documentation required in schedule 2 of the Care Standards Act 2000 (Establishments & Agencies)(Miscellaneous Amendments 2004) except for one, which only had one written reference but there was evidence of a verbal reference taken over the phone. In discussion with the manager they agreed to chase this up. In discussion with a member of staff they reported that when the home are interviewing staff two of the residents are involved on the interview panel and ask questions of their choice.
Sea Gables DS0000012587.V327207.R01.S.doc Version 5.2 Page 21 In the information provided in the pre-inspection questionnaire the manager has reported that the home currently employs eleven care staff, six of which have completed National Vocational Qualification (NVQ) level 2 in care. This equates to 65 of care staff having NVQ level 2 in care this has been a significant increase since the last inspection. A copy of the staff, training matrix was returned prior to the inspection visit and indicated that nine staff had undertaken adult protection training between November 2006 and February 2007. There was evidence of training planned in food hygiene, first aid, manual handling and infection control. Seven staff had received renewal training in medication administration. In discussion with one member of staff they reported that the medication, training had been facilitated by the Isle of Wight College. There was evidence that new staff are following a comprehensive induction programme, however this did comply with the skills for care induction training of which the manager had no knowledge. Sea Gables DS0000012587.V327207.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect. The manager is experienced in caring for people with learning difficulties but has not yet qualified. The manager does not have quality assurance systems in place and these require developing. The service promotes equality and diversity in meeting the needs of the residents. Sea Gables DS0000012587.V327207.R01.S.doc Version 5.2 Page 23 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. A requirement was made at the last inspection that the registered manager must complete the NVQ level 4 in care and Registered Manager’s Award by October 2006 as they had previously indicated that this would be completed by January 2006. In discussion with the manager they reported that they had not been able to meet this requirement however they were near completion and would have completed the training by the end of 2007. The manager demonstrated a positive and open management approach and clearly had a good working relationship with the residents, relatives and staff. In discussion with the manager they reported that on occasion they have had to arrange for independent advocates to support residents to enable them to discuss there future wishes 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 the homes quality assurance procedures with the manager. The manager reported that they still asked residents about their views on specific aspects of the service such but had still not document these conversations. The home does not undertake an annual audit of the service asking for the views of residents, relatives and stakeholders. There is no annual renewal programme with works maintenance works being done as required and the home being re-decorated and furnished as required. The manager reviews and updates policies and procedures in line with changes in legislation and good practice recommendations from the Department of Health. The manager ensures that staff adhere to heath and safety procedures within the home buy setting an example and providing mandatory training which includes health & safety in the workplace, food hygiene, manual handling, fire safety and infection control. The home has a locked storage facility for substances considered hazardous to health (COSHH).
Sea Gables DS0000012587.V327207.R01.S.doc Version 5.2 Page 24 A COSHH risk assessment has been undertaken on all cleaning products. In discussion with one staff member they demonstrated that they knew the homes fire procedures and would know what action to take in the event of a fire. There was evidence that the homes Fire systems are routinely tested every week and records maintained. Fridge and freezer temperatures are checked twice daily and records of these are kept. In discussion with the manager they reported that the home also receives a check of the temperatures of the food delivery van to ensure foods have been transported safely. The home also has a probe for checking the temperature of cooked meals before being served to minimise the risk of food poisoning. The manager ensures that boilers and central heating systems are serviced regularly. Portable electrical appliances are checked annually. All accidents, injuries and illness or communicable diseases are recorded and those of a serious nature are reported to CSCI. Sea Gables DS0000012587.V327207.R01.S.doc Version 5.2 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 x 3 2 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 x 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 x 4 x LIFESTYLES Standard No Score 11 x 12 4 13 4 14 x 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 1 x x 3 x Sea Gables DS0000012587.V327207.R01.S.doc Version 5.2 Page 26 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. 1. YA39 24 (1) (a) & (b) You are required to develop 30/05/07 effective quality assurance and quality monitoring systems. This will ensure that the views of the residents underpin review and development of practice within the home. 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 YA20 YA19 YA22 Good Practice Recommendations Those staff responsible for the administration of medication must always sign the records. Residents would benefit from the incorporation of annual health checks as part of their health action plan. Residents would benefit from the development of the complaints procedure in an accessible format. Sea Gables DS0000012587.V327207.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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