Inspection on 02/03/06 for Sea View Lodge

This inspection was carried out on 2nd March 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sea View Lodge 04/08/09

Sea View Lodge 18/05/09

Sea View Lodge 19/06/08

Sea View Lodge 26/06/07

Sea View Lodge 22/11/06

Sea View Lodge 23/06/06

Sea View Lodge 31/05/05

Sea View Lodge 14/12/04

Sea View Lodge 30/03/04

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

CARE HOME ADULTS 18-65 Sea View Lodge 116 Central Parade Herne Bay Kent CT6 5JN Lead Inspector Joe Harris Announced Inspection 10:00 2 March 2006 nd Sea View Lodge DS0000023424.V272945.R01.S.doc Version 5.0 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 View Lodge DS0000023424.V272945.R01.S.doc Version 5.0 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 View Lodge DS0000023424.V272945.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Sea View Lodge Address 116 Central Parade Herne Bay Kent CT6 5JN 01227 375253 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 Shahid Sheikh Mrs Nelofar Sheikh Mr Shahid Majeed Sheikh Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Sea View Lodge DS0000023424.V272945.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Residents shall be 30 years of age and over Date of last inspection 31st May 2005 Brief Description of the Service: Sea View Lodge is a 10-bedded home for people with learning disabilities in the town of Herne Bay. The house is located on the seafront close to the pier and a short distance from the centre of town with a good range of amenities and facilities. There are reasonable public transport from the town including bus routes and a train station. The home is set out over two floors. The ground floor mainly comprising of communal space with two bedrooms and the first floor consisting of bedrooms and toilets/bathing facilities. There is adequate communal space throughout the home with more space available following refurbishment. There is a small, enclosed courtyard to the rear of the home and a larger paved area with parking space to the front of the home. Sea View Lodge DS0000023424.V272945.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over two days on the 2nd and 3rd March 2006 by two inspectors. The inspection lasted approximately 12 hours in total. During the course of the inspection discussions were held with the registered manager, all staff and all service users. A detailed tour of the premises was undertaken and a wide range of documents were viewed relating to the service users, staff, health and safety and the running of the business. Service user feedback leaflets were returned having been completed by individuals with the assistance of the registered manager or family members providing generally positive feedback about the home. As a result of this inspection 7 requirements and 10 recommendations have been made. What the service does well: What has improved since the last inspection? The registered manager has responded positively to requirements and recommendations made from previous inspections and has addressed or begun to address environmental issues previously noted. Documentation has Sea View Lodge DS0000023424.V272945.R01.S.doc Version 5.0 Page 6 continued to improve in respect of service user plans, recruitment files, polices and procedures and some health and safety information. The home has also taken on board advice from the Commission pharmacist regarding improvements to medication procedures and storage facilities. The registered manager has also made progress in respect of the training needs of staff and there was evidence that some courses have already been provided and dates for future training planned. 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. Sea View Lodge DS0000023424.V272945.R01.S.doc Version 5.0 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 View Lodge DS0000023424.V272945.R01.S.doc Version 5.0 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): 1, 2, 3, 4 and 5. Prospective service users are provided with adequate information about the service. Individual needs and aspirations are assessed prior to admission and the home ensures that these needs will be met. There are opportunities for trial visits prior to choosing whether to move in. Service users are provided with a statement of terms and conditions of residency. EVIDENCE: The registered manager has developed a statement of purpose and recently reviewed this document ensuring that all pertinent information is included. A service user’s guide has also been developed and the registered manager stated that all new referrals to the service will be given a copy of this information. The service user’s guide covers key points from the statement of purpose and other relevant information. Some thought should be given to producing a more accessible format for people with communication problems and learning disabilities. The majority of service users admitted to the home have been referred through care management processes and documentation was available on individual files demonstrating that adequate information is provided regarding assessed needs on an on-going basis including reviews and care management risk assessments. No new service users have been admitted for some time, but the registered manager confirmed that he will ensure that the home is provided with adequate information. In addition to this he has developed a pre-admission assessment tool, which is detailed and covers all aspects of health and social support. The registered manager stated that he intends to Sea View Lodge DS0000023424.V272945.R01.S.doc Version 5.0 Page 9 use this assessment format for all service users referred to the home in conjunction with care management information where applicable. The home provides a service for people with learning disabilities and has established links with local community learning disability teams and resources. There is a small staff team with the registered manager taking a ‘hands on’ role in the home. Two staff have relatively recently been employed through an overseas recruitment agency and trained as nurses in their country of origin. Another member of staff has worked in the caring profession for a number of years. Staff would benefit from additional training relating to the care and support of people with learning disabilities. Refer to recommendation 1. The registered manager and staff demonstrated a thoughtful and sensitive approach to communicating with service users. There is access to information regarding advocacy services should this be required. The home does not currently offer a respite service. It was reported by the registered manager that any new or prospective service users are offered trial visits to the home commencing with short visits up to an option of a 1-week stay without charge. The home seeks to avoid emergency admissions, but all admission criteria would be met in any such circumstance. The service provides a written contract covering the terms and conditions of residency. A copy of the contract is given to the service users and/or their representatives and a copy retained on file. Sea View Lodge DS0000023424.V272945.R01.S.doc Version 5.0 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, 9, 10. Service users needs are adequately reflected in the individual plans. Service users are able to make decisions about their lives, although consideration should be given to the role of appointees and the management of resident finances. Service users are consulted about aspects of life in the home, although further efforts could made to improve this. There is an adequate risk management process in place. Information about service users is handled in a confidential manner. EVIDENCE: A number of service user plans were viewed at random, all of which provided good levels of information regarding service users and clearly reflected and addressed assessed needs. The registered manager has completed a lot of work with regard to service user plans, which are informative and well set out. The service user files contain an information sheet covering essential information, likes, dislikes and issues of concern. A pen portrait has also been developed providing a very good and easily accessible resource enabling a good understanding of each resident’s background, likes, dislikes and preferences. Care plans are also informative and provide good guidelines to enable staff to meet needs in a consistent manner. A discussion was held with the registered manager regarding care planning and, in a few cases, more Sea View Lodge DS0000023424.V272945.R01.S.doc Version 5.0 Page 11 information could be provided, but needs were still adequately addressed. The plans are also hand written and were a little bit difficult to decipher at times. It was suggested that they should either be written in block capitals or typed in future to avoid this. Service users are enabled to make decisions regarding their day-to-day lives. Throughout the course of the two-day inspection staff were observed to consult service users and promote decision-making with regard to day-to-day activities such as choosing whether to go out to planned clubs/day services, choice of food and activities within the home. One resident said, “this is my home and I can do the things that I want to do” and another individual stated, “I didn’t want to go out today because of my leg”. A discussion was held with the registered manager regarding the management of service users finances for whom he is appointee. Currently, benefits are paid directly into the business bank account and then the money is transferred into service users personal accounts. It was advised that the service users monies should be paid into a separate account not associated with the business. The registered manager agreed to investigate these options further. Refer to recommendation 2. There was evidence and confirmation from residents that they are able to participate in the day-to-day running of the home. Some service users take roles in tasks around the home and are consulted on trips out, menus and other aspects of the service. There was some evidence of recorded resident meetings, however these were infrequent and included staff meetings. This was discussed with the registered manager who was advised that these meetings should happen on a more frequent basis, i.e. every 1-2 months and that staff meetings should be held separately. Refer to recommendation 3. The registered manager has developed an adequate process of individual risk assessment, which is formulated in conjunction with care management documents and care plans. It was noted that despite risk being identified, risk management plans could be provided in greater detail clearly demonstrating how perceived risks will be minimised and clarifying guidelines for staff to enable this. Risk assessments are regularly reviewed and there is a missing persons procedure in operation. Information regarding service users is maintained in a confidential manner, with records held securely in a locked cupboard. No personal information was seen to be on display within the home. Staff were aware of issues of confidentiality and do not discuss issues of a personal nature openly. The home has a policy in place addressing issues of confidentiality. Sea View Lodge DS0000023424.V272945.R01.S.doc Version 5.0 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, 15, 16 and 17. There are opportunities for personal development and the chance to take part in other activities. Service users have access to community facilities and leisure activities although more structure and a wider range of activities could be introduced. Personal relationships are enabled and encouraged, rights and responsibilities are respected. An adequate diet is provided and service users enjoy their meals. EVIDENCE: Service users are supported to maintain and develop activities of daily living in the home and through outside activities. Some service users take on roles within the home depending on their skills and interests and continue to manage their own finances. Residents have the opportunity to shop for their own clothes and personal effects. A number of individuals attend local day centres providing similar support and two residents have been attending evening classes at a local college for some time. The home enables service users to attend religious services if they wish to do so. The registered manager stated that he plans to employ an additional staff member, which will enable greater flexibility to support service users in the local community. There are reasonable public transport links and the registered manager uses his own Sea View Lodge DS0000023424.V272945.R01.S.doc Version 5.0 Page 13 vehicle to transport service users when required. The home is set on the seafront and is close to all local amenities. Some leisure activities are organised from the home and the service users went on a weeks holiday to Blackpool in the summertime. Residents choose the activities they wish to participate in such as knitting, colouring, watching television and listening to music. It was suggested that the home could be more proactive in offering different activities and encouraging more group activities within the home. One service user stated that “I would like to go on more trips out” and another resident said, “I get a bit bored sometimes”. However one other individual made it clear that “I like to do my own thing, I’m happy spending time in my room and go out when I want to”. It was advised that a weekly programme of events should be introduced and the registered manager could investigate the option of introducing an outside entertainer and/or therapist, as well as organising games sessions such as bingo or quizzes depending on the interests of the service users. In addition to this it was noted that daily records concentrate on the routine aspects of the day and are brief and relatively uninformative. It was advised that staff should highlight the activities that residents undertake in the home and the nature of interactions and time spent with individuals. Refer to recommendation 4. Visitors are welcomed into the home at all reasonable times and service users are encouraged to develop and maintain relationships outside the home. Resident’s wishes with regard to daily routines are respected. Staff knock before entering rooms and are addressed in a manner that they are accustomed to. Staff were observed to spend time with service users engaging in social conversation and treating individuals in a respectful and thoughtful manner. Residents are able to choose when they wish to be alone or spend time in the company of others and have unrestricted access around the home. Some service users take an active role in the household tasks and are encouraged to do so with regard to their wishes. A lunchtime meal was observed, which was relaxed, unhurried and informal. The dining area is adequate for the needs of the home and service users can choose when and where to eat. All of the service users had chosen different meals ranging from sandwiches to hot snacks. Menu records show a reasonable balanced diet and residents stated, “the food is good, if I don’t like the meal the staff will make me what I want”. The registered manager stated that any special diets are catered for and one resident has diabetes, which is managed in conjunction with the diabetic nurse. Sea View Lodge DS0000023424.V272945.R01.S.doc Version 5.0 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): 18, 19 and 20. Service users receive personal support as they prefer and healthcare needs are met. Medication processes are adequate. EVIDENCE: Service user plans clearly detail the personal support required for each individual and provide guidelines and information regarding how this should be provided, taking into account service user wishes. Personal support is provided in private settings. One service user stated, “the girls are lovely, they are friendly and caring”. Service users can choose when they get up and go to bed and determine other daily routines as they wish. Support is provided to enable residents to choose their own clothes and meet personal grooming needs. The home maintains healthcare records satisfactorily showing evidence of input from healthcare professionals, actions and outcomes. All service users are registered with a local GP and any nursing needs are appropriately met by relevant professionals. Additional healthcare needs such as dentist, chiropodist and optician input is provided and service users are supported to attend these appointments. The home maintains contact with care managers and care reviews occur on a reasonably frequent basis. Any healthcare consultations in the home can take place in a private area. The home has adequate policies and procedures with regard to medication processes. New medication storage facilities have recently been installed following recommendations from the Commission pharmacist. Medication Sea View Lodge DS0000023424.V272945.R01.S.doc Version 5.0 Page 15 Administration Records were well kept, up to date and complete. Storage facilities are adequate and medications well organised. No controlled drugs are in use. None of the service users are currently self-medicating. Some staff have had medication training and this is planned for the newer staff who have recently joined the home. It was suggested that the home obtains an up to date copy of the BNF for reference regarding medications. Sea View Lodge DS0000023424.V272945.R01.S.doc Version 5.0 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. There is an adequate complaints process in place. Service users are protected from forms of abuse, although further training in adult protection issues is recommended. EVIDENCE: There is an adequate complaints process in place covering all relevant topics. A copy of this is provided in the service user’s guide and is on display within the home. The registered manager stated that he aims to deal with any issues of concern or complaint in an informal manner in the first instance, but should this prove unsatisfactory would advise individuals to make use of the formal complaints process. It was reported that there have been no complaints since the last inspection. A complaints book is in place to record issues of note and demonstrate the actions taken. Service users stated that they felt comfortable in raising concerns with the registered manager and staff. The home has adequate policies and procedures in place addressing issues of abuse and adult protection, which include a whistle-blowing policy. Issues of abuse are addressed through the induction process, however it was noted that in the case of the two newer staff this had not been signed off and dated. It was strongly recommended that all staff take part in additional training regard adult protection and abuse to update knowledge and increase awareness of processes, which the registered manager agreed to do. Refer to recommendation 5. The registered manager showed an awareness of the home’s obligations in accordance with the Protection of Vulnerable Adults register and associated legislation. Policies and practices with regard to the handling of service users money and valuables, safe storage and access to records is adequate. Sea View Lodge DS0000023424.V272945.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 and 30. Service users live in a homely environment that would benefit from some additional work and updating. Some attention is required with regard to health and safety issues such as radiator covers. Bedrooms are of an adequate size, but would also benefit from some updating. Toilet and bathing facilities are adequate. Shared spaces are suitable. The home is generally clean and hygienic, although work is required to ensure that the laundry area is suitable for the needs of the home. EVIDENCE: The registered manager has, over recent times, invested time and money in beginning to update the environment and he acknowledged that there is further work to be completed stating that, in the coming year, plans are in place to address outstanding issues that have been identified. Sea View Lodge is situated on the seafront and is close to the town’s amenities. The building is set out over two floors with communal space, kitchen, laundry and two bedrooms on the ground floor and further bedrooms and bathing facilities on the first floor. New carpets have been laid in the vast majority of bedrooms and in the hallway and on the stairs. A programme of redecoration is on going throughout the building with a number of the bedrooms having been completed. There is an extension to the rear of the building, which is planned for major refurbishment. There is a small, enclosed courtyard to the rear of the Sea View Lodge DS0000023424.V272945.R01.S.doc Version 5.0 Page 18 home and a larger paved area to the front of the building where a number of service users like to sit out in the warmer months. The premises are generally bright, well lit and comfortable, although some of the furniture throughout the building would benefit from renewal and updating. In addition to this much of the pipe work and radiators are uncovered and have no means of central regulation. These issues were discussed with the registered manager who agreed to develop an action plan addressing the renewal and replacement of furniture and guarding radiators and pipe work. Refer to requirements 1 and 2. All bedrooms are single occupancy and of sufficient size to meet the needs of the service users meeting minimum requirements. All of the service users stated that they were happy with their bedrooms and it was evident that they had been personalised according to taste. In a number of the bedrooms, however, attention is required to the furniture and fittings, which was discussed with the registered manager. Refer to requirement 2. The majority of bedrooms have been recently decorated and recarpeted and this process remains on going. Suitable locks have been fitted to the majority of doors to rooms and plans are in place to address any outstanding issues in this area. Toilets and bathing facilities are adequate for the needs of the home, although there is currently no toilet on the ground floor, which the registered manager intends to address when the extension is refurbished. There is adequate communal space in the home with a large main lounge/dining area, which is comfortable and homely in nature. There is additional space to the rear of the home, which is currently used for meetings and administrative work. The kitchen is adequate for the needs of the service with suitable storage space. The laundry area is sited off the kitchen and is also used as additional communal space. The area around the washing machine was unhygienic with loose carpet tiles and no work surface space. It is required that this area is updated to include suitable flooring, tiled walls and workspace, leaving the remainder of the room for other uses. Refer to requirement 3. Due to the layout of the building laundry has to be carried through the kitchen, which is unavoidable. It was advised that a risk assessment and procedure should be implemented to ensure that laundry is not transported through the kitchen when food is being prepared or served to reduce the risk of cross-infection. The registered manager agreed to address these issues. Refer to recommendation 6. The home was generally clean and hygienic in all other respects. Procedures are in place regarding the control of infection and hazardous substances are stored securely. There are adequate hand washing facilities available throughout the home. The washing machine and tumble drier are adequate for the needs of the home. Sea View Lodge DS0000023424.V272945.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36. There are clear staff roles and responsibilities, however staff are required to have GSCC codes of conduct. Staff are competent in their roles and further NVQ training is planned. There is a small staff team that meets minimum requirements. Recruitment practices are satisfactory. Further training is planned to ensure all staff have the required mandatory courses. Systems of supervision need to be reviewed and improved. EVIDENCE: Staff in the home were clear about their roles and responsibilities and are provided with a job description on appointment. There was a clear understanding of the aims of the home and staff work positively with service users in order to achieve this. The registered manager was informed that all staff should be provided with copies of the General Social Care Council code of conduct, which he agreed to follow up. Refer to requirement 4. There is a small staff team in the home, two members of which have recently been recruited through an accredited overseas recruitment agency. Both of these staff have qualifications in nursing from the countries of origin. However it was advised that these staff should progress to undertake appropriate National Vocational Qualifications. Refer to recommendation 7. Another staff member has achieved her NVQ level 2. All staff were observed to be open, approachable and comfortable with service users and had developed positive relationships. There are generally 2 staff on duty throughout the day and a member of staff sleeping-in at night time. On one occasion on the staff rotas viewed was there Sea View Lodge DS0000023424.V272945.R01.S.doc Version 5.0 Page 20 only 1 member of staff on duty. The home meets the minimum staffing requirements in accordance with department of health guidance, however the registered manager stated that he plans to employ another carer in the near future, which will enable more flexibility and have the impact of reducing the number of hours some of the staff work, which is rather high at times. The registered manager should introduce more regular and structured staff meetings. Some evidence was available that these had occurred, but on an infrequent basis. He agreed to address this issue. Refer to recommendation 8. Recruitment practices were adequate with all staff having provided two written references and all CRB/POVA checks completed. Overseas staff have been recruited through a Home Office approved recruitment agency and all documentation in this regard was present and available for inspection. All staff receive a statement of terms and conditions of employment. The registered manager underlined his commitment to improve the levels of training offered to staff and evidence was available to demonstrate that training courses have been provided and are planned for the future. Some staff have not completed all their mandatory training and updates, but this is being addressed. Refer to recommendation 9. The registered manager also stated his intention to begin use of the Common Induction Standards. An induction checklist is currently in place addressing all relevant issues, but the Skills for Care induction standards would provide improved levels of evidence to demonstrate that the key topics have been satisfactorily addressed. The registered manager currently provides supervision and support through informal means and staff stated that they feel that they receive adequate support. However, it is required that a formal process of 1:1 supervision is introduced with recorded meetings and clear action points to ensure accountability and staff development. This was discussed with the registered manager who agreed to implement such a system. Refer to requirement 5. The registered manager has undertaken supervision and appraisal training. Sea View Lodge DS0000023424.V272945.R01.S.doc Version 5.0 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 41 and 42. The registered manager has necessary qualifications and experience. There is a system of informal quality assurance. Adequate policies and procedures are in place including record keeping to safeguard service user’s rights. Health and safety issues are generally met although some shortfalls need to be addressed. EVIDENCE: The registered manager has a number of years of experience owning and managing in the care setting and working with people with learning disabilities. He has achieved his NVQ level 4/RMA and has relevant qualifications in business management. Throughout the inspection he was open to advice and suggestions and demonstrated a commitment to continue to improve and develop the service. He continues to undertake periodic training to update and gain new skills. The home does not have a formal system of quality assurance in place as the registered manager is also the homeowner. However, it could be demonstrated that plans are in place to develop the service and monitoring of aspects of the running of the home takes place. This was evident in regard to the environment, documentation and future service developments. It was Sea View Lodge DS0000023424.V272945.R01.S.doc Version 5.0 Page 22 suggested that an annual plan could be developed highlighting areas of improvement on an on going basis. It would also be recommended that a system questionnaires for service users, families, professionals and other stakeholders is introduced providing constructive feedback. Refer to recommendation 10. The home has implemented adequate policies and procedures covering a range of topics and all relevant issues. The policy and procedure file is accessible to all. Staff are also requested to sign off new policies and procedures when they have been read. There was evidence that these documents are reviewed and updated on a periodical basis. There are adequate processes in place to ensure appropriate record keeping practices. Information is held securely and there is an access to records policy in accordance with the Data Protection Act 1998. Although the majority of issues surrounding health and safety were met some aspects were outstanding. All service checks and certificates were in place except for an up to date CORGI gas safety certificate. There was evidence that the gas safety engineer was due to attend and the registered manager agreed to forward a copy of this certificate on completion of the work. Refer to requirement 6. Fire safety logs and accident records were satisfactory with one exception. The registered manager had not developed a fire safety risk assessment as required by the fire safety authorities. The registered manager agreed to address this issue. Refer to requirement 7. The home has documents and procedures in place to ensure safe working practices and mandatory training issues are in the process of being addressed. A number of environmental risks were noted; refer to requirements 1,2 and 3. Sea View Lodge DS0000023424.V272945.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 2 3 3 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 2 2 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 1 3 1 3 3 X 1 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 1 2 3 3 2 1 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sea View Lodge Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 2 3 3 1 X DS0000023424.V272945.R01.S.doc Version 5.0 Page 24 Yes 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 YA26YA24 Regulation 16, 23 Requirement To produce an action addressing the updating of furniture and fittings throughout the home where identified. To produce an action plan prioritising the fitting of radiator covers and guarded pipework. To ensure that the laundry area is maintained to adequate levels of hygiene and is suitable for the needs of the home. To ensure all staff receive copies of the GSCC code of conduct To develop a system of formal, recorded 1:1 supervision for all staff. To forward a copy of the current CORGI gas safety certificate on completion of the assessment. To develop a fire safety risk assessment. Timescale for action 01/05/06 2 3 YA24 YA30 16 13, 16 01/05/06 01/05/06 4 5 6 7 YA31 YA36 YA42 YA42 18, 19 18 13, 23 13, 23 01/05/06 01/05/06 15/03/06 01/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Sea View Lodge DS0000023424.V272945.R01.S.doc Version 5.0 Page 25 No. 1 2 3 4 5 6 7 8 9 10 Refer to Standard YA3 YA7 YA8 YA14 YA23 YA30 YA32 YA33 YA35 YA39 Good Practice Recommendations To provide training for all staff covering care practices for people with learning disabilities. The registered manager to investigate alternative arrangements for the handling of service users finances for whom he is appointee. To ensure regular resident meetings promoting participation in the day-to-day running of the home. To develop a weekly timetable of planned activities introducing a wider range of available activities dependent on the needs and wishes of service users. To ensure all staff address issues of abuse through the induction process and additional training courses. To develop a risk assessment and procedure for transporting laundry through the kitchen area ensuring the control of infection. To continue to enable staff to undertake relevant NVQ training. To hold monthly, recorded staff meetings. To continue to update all mandatory training and other relevant courses to meet service users needs. To introduce service satisfaction questionnaires to enable all stakeholders to provide constructive feedback and opinions. Sea View Lodge DS0000023424.V272945.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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. 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