Inspection on 23/06/06 for Sea View Lodge

This inspection was carried out on 23rd June 2006.

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

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

Other inspections for this house

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 02/03/06

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 Joseph Harris Unannounced Inspection 23rd June 2006 09:30 Sea View Lodge DS0000023424.V297534.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Sea View Lodge DS0000023424.V297534.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 View Lodge DS0000023424.V297534.R01.S.doc Version 5.2 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.V297534.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Residents shall be 30 years of age and over Date of last inspection 2nd March 2006 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. The current fees for the service at the time of the visit range from £398 to £560. Information on the home services and the CSCI reports for prospective service users will be detailed in the statement of purpose and service user guide. Sea View Lodge DS0000023424.V297534.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 23rd June 2006 at 9.30am and lasted for approximately 7.5 hours. During the course of the site visit discussions were held with 4 service users and 3 care staff. The registered manager was not on site at the time of the visit. A tour of the premises was conducted and records pertaining to service users, staff and the running of the home were examined. What the service does well: What has improved since the last inspection? There have been a number of improvements since the last inspection including an emphasis on staff training, improving the general environment through redecoration and new carpets. The registered manager has produced an action plan addressing other proposed improvements to the environment including the provision of radiator guards, work on the laundry area and the renewal of some furniture and fittings. Work has also been completed on health and safety issues including the development of a fire risk assessment and ensuring all routine maintenance tests such as PAT testing and gas safety checks are completed. There are three relatively new staff who have been provided with training working towards meeting the necessary requirements and additional training including adult protection issues. Systems have also been introduced to provided structured support and supervision and regular staff and resident meetings. All requirements made at the last inspection have been or are in the process of being addressed. Sea View Lodge DS0000023424.V297534.R01.S.doc Version 5.2 Page 6 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.V297534.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 View Lodge DS0000023424.V297534.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 5. Individual needs and aspirations can be assessed and prospective service users know that the home will be able to meet their needs. Each service user is provided with a written contract. Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. EVIDENCE: There have been no new service users admitted to the home since the last inspection. As a result it was not possible to fully examine the assessment process. However, the registered manager has developed new and improved assessment tools addressing the holistic needs of prospective service users. The home also ensures that existing service users continue to receive support from care managers and care is reviewed on this basis. The home has the capacity to meet the needs of service users entering the home. Service users confirmed that the staff are friendly and helpful and meet their needs in the ways that they wish. There is a relatively new staff team in place, two of which showed a reasonable level of understanding about the needs of the service users. It is advised, however, that the staff team, all of whom are trained nurses from China, would benefit from additional training regarding learning disabilities such as the Learning Disability Award Framework (LDAF). Refer to recommendation 1. There are no service users admitted for respite or short-term care. The home provides each service user with a written contract covering all the keys terms of residency including fees. A copy of each contract is retained on file. Sea View Lodge DS0000023424.V297534.R01.S.doc Version 5.2 Page 9 Sea View Lodge DS0000023424.V297534.R01.S.doc Version 5.2 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 and 10. Each service user has an individual plan and risk assessments, but these are in need of review and updating in line with changing needs. Service users are able to make decisions about their lives and can participate in the day-to-day running of the home. Information is retained in a confidential manner. Quality in this outcome area is adequate. This judgement has been made using all of the available evidence including a site visit to this service. EVIDENCE: Three service user files were examined all of which contained relevant information relating to the individuals. A pen portrait has been developed providing a good overview of each service users general needs, likes and other relevant information. A plan of care has also been developed addressing needs and aspirations in adequate detail. It was noted, however, that the plans were overdue a review and some plans would benefit from updating in line with resident’s current and changing needs. A number of the service users have reduced mobility and, as a result, no longer attend outside activities such as day centres, but this is not reflected in the plans of care. Refer to recommendation 2. Risk assessments have also been completed for all service users, but similarly these are also in need of review and updating on the same basis. Refer to recommendation 4. Sea View Lodge DS0000023424.V297534.R01.S.doc Version 5.2 Page 11 Service users are able to make choices surrounding their day-to-day lives and participate in the daily running of the home as they wish. Service users confirmed that staff assist them to make daily choices and that there is a relaxed atmosphere in the home. Where restrictions are necessary for the purposes of safety or protection these issues are documented and discussed with the individuals and/or their representatives. The details of financial support/appointeeship were not assessed at this inspection and will be addressed at the next site visit to the service. Service users stated that they have a say in the daily running of the home through resident meetings and can become involved in the household chores such as food preparation and cleaning should they wish to do so. Resident meetings are recorded, but the information held on file is brief and states topics discussed only. It is advised that the registered manager and staff document details of the issues discussed at resident meetings and any outcomes or actions arising from this to ensure clear feedback for service users. Refer to recommendation 3. Information held regarding service users was seen to be handled in a confidential manner and staff were sensitive to issues of confidentiality. There is an access to information policy in place. Sea View Lodge DS0000023424.V297534.R01.S.doc Version 5.2 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): 12, 13, 14, 15, 16 and 17. Some service users have opportunities to take part in meaningful activities, but these opportunities are limited to those who are able or wish to attend external centres. Service users can access the local community, although some residents with mobility problems are less able to do so. There are limited opportunities for leisure activities available for service users. Service users can maintain appropriate relationships. Service user’s rights are respected in their daily lives. A healthy, balanced diet is offered and service users enjoy their meals and mealtimes. Quality in this outcome area is adequate. This judgement has been made using all of the available evidence including a site visit to this service. EVIDENCE: A number of the service users attend a local day centre a number of times per week, but three of the residents have reduced levels of mobility and choose not to attend the centre or other activities outside of the home any more. One service user said “I can’t get out much anymore, but I’m happy staying in, I don’t go to the club now.” Another service user has been suffering with knee problems and is waiting for a knee replacement and stated “I can’t go out until I get this sorted out”. In light of the changing needs of some of the service users it is advised that the registered manager reviews the level of activities in Sea View Lodge DS0000023424.V297534.R01.S.doc Version 5.2 Page 13 the home and considers introducing meaningful activities into the home. Refer to recommendation 5. Similar consideration should also be given to the provision of leisure activities and the ability of some individuals to access outside resources. According to the daily records service users have regular routines and limited activities during the day. Whilst it is acknowledged that service users do not necessarily wish to have overly busy days, it would be beneficial for people to have the option of regular activities which provide some diversity to day-to-day life, such as introducing an outside entertainer, arranging art and craft sessions, bingo or quizzes and other similar activities. Staff time each day could also be given to social and recreational activities rather that concentrating on the routines of the home, which could include art, music or other such activities. One resident said, “It would be nice to have some more activities in the house, we used to have an exercise lady visit, but she doesn’t come anymore.” When asked directly two service users said “It would be lovely to have an entertainer visiting to do some of the old songs.” Refer to requirement 1. Staff stated that they do go out on a regular basis with two of the residents into the local community and take walks into the town and along the seafront. As previously noted a number of the other residents have reduced mobility and if they require any shopping ask staff to get it for them. These residents stated that they are happy staying in and did not express any particular desire to go out. The registered manager has improved the areas outside the home and there is comfortable area at the front of the home for service users to sit out taking in the sea air. Service users stated that any friends and family are welcomed into the home, although it was also reported that not many people have a great deal of visitors. One resident said “This is my family, we’re all friends and we get on very well.” She went on to add, “It would be nice to have some new people move in though.” Service users confirmed that staff respect their individual rights and freedom. “The staff are lovely, they help whenever I need anything.” Staff were observed to be respectful of individuals space and spoke to residents in a caring and thoughtful manner. All service user’s rooms are lockable, but noone chooses to lock their rooms. Residents can take part in household tasks if they wish to do so and some have regular tasks that they choose to take part in. Menu records were viewed, which show that a healthy, balanced diet is provided. A good range of food was available in the home including fresh fruit and vegetables along with a range of reasonable quality frozen foods and other non-perishables. All of the service users commented that the food was good and that they could choose what they wanted to eat if they did not like what was on the menu. Mealtimes are taken in an unhurried and relaxed atmosphere and service users can choose when and where to eat. Staff also showed an awareness of the likes and dislikes of service users in this regard and of any specific nutritional needs. Sea View Lodge DS0000023424.V297534.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 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 in the way that they prefer and physical and emotional healthcare needs are met. Medication processes and procedures are adequately managed. Quality in this outcome area is adequate. This judgement has been made using all of the available evidence including a site visit to this service. EVIDENCE: Staff provide service users with sensitive and dignified personal support. It was evident in discussion with two of the staff on duty that they have a good awareness of the individual personal support needs and preferences of each of the service users. The service user plans, although in need of some updating, satisfactorily address the main care needs of residents and provide clear guidance on the methods by which people wish to be assisted. One service user said “The staff are very helpful and they help me with my bath when I need it.” Another resident stated that “We very happy, we get everything we need.” Service users can choose when they get up and go to bed and there is a reasonable level of flexibility within the daily routines to enable freedom of choice. It was evident from service user records that the home addresses healthcare needs appropriately and service users are supported to attend appointments. Healthcare issues that are highlighted are followed up and referred appropriately. Evidence was also available to demonstrate that care managers Sea View Lodge DS0000023424.V297534.R01.S.doc Version 5.2 Page 15 have visited service users relatively recently to assess current needs. Service users are referred for additional healthcare support from audiologists, dentists and opticians as required. A chiropodist visits the home every 6 weeks. All service users are registered with a local GP and visit as required. Medication records were examined and maintained to a good standard with clear recording and no apparent gaps in administration. Storage facilities are adequate and have been installed in accordance with advice following a visit by a CSCI pharmacist. None of the current service users are self-medicating. Records are maintained of all medication entering and leaving the home. Staff have received training in basic administration techniques and all of the care workers are trained nurses from China. The home has adequate policies and procedures in place, which should remain under review in line with current practice and guidance. Sea View Lodge DS0000023424.V297534.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Service users feel that their views are listened to and acted upon. Residents are protected from forms of abuse. Quality in this outcome area is adequate. This judgement has been made using all of the available evidence including a site visit to this service. 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. 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. Two staff have attended courses recently covering adult protection issues and abuse awareness. In discussion with staff there was a reasonable awareness of what action would be required should they witness or suspect abuse. 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.V297534.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28 and 30. Service users live in a homely and comfortable environment. All bedrooms are single occupancy and meet the needs of the service users, although some aspects of furniture and fittings could be renewed. Toilets and bathrooms meet individual needs. There are adequate and comfortable shared spaces. The home is clean and hygienic. Quality in this outcome area is adequate. This judgement has been made using all of the available evidence including a site visit to this service. EVIDENCE: A tour of the premises was undertaken and all areas of the home appeared reasonably well maintained, clean and comfortable. In discussion with service users it was evident that they are proud of their home and added that “Mr Sheikh is trying hard to get things done around the home”. Another resident remarked that “the house has been decorated and looks good, I’m pleased about the new carpets”. There remains aspects of work to complete, but the registered manager has submitted an action plan addressing this and has completed work in accordance with this at the present time. It was noted that one resident would like a new armchair in her room, which is somewhat threadbare and, aesthetically, the home would benefit from new lampshades in hallways and a number of the bedrooms. The registered manager has stated his intention to replace at least 5 chairs in resident’s rooms as part of the Sea View Lodge DS0000023424.V297534.R01.S.doc Version 5.2 Page 18 renewal of furniture and fixtures as stated in a previously submitted action plan. There is adequate communal space within the home with an unused room to the rear of the house, which could be cleared out, decorated and used as further communal space if required. The patio area to the front of the home has been improved and provides a pleasant space for service users to sit out in the summer. Work has also begun to clear the small patio space to the rear of the home. All of the service users spoken to stated that they like their bedrooms and have all the things that they need. There are adequate numbers of toilets and bathrooms throughout the house, although there is no communal toilet on the ground floor, which is worth consideration for the future. There is a static bath chair in the first floor bathroom for those with difficulty getting in and out of the bath, although no maintenance records were found in relation to this. The registered manager has begun a programme of installing radiator guards throughout the home and has produced an action plan for this work. The laundry area in the utility room has been improved with impermeable flooring and tiling around the washing machine. A policy has also been instituted to ensure that laundry is not carried through the kitchen at times of food preparation. The laundry would benefit from some shelving or worktop space for sorting and arranging laundry. Refer to recommendation 6. The home appeared clean and hygienic throughout with no issues of note in regard to hygiene. Sea View Lodge DS0000023424.V297534.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. Service users are supported by caring and competent staff who would benefit from competency based training. There are adequate numbers of staff on duty at all times, however there is room for improvement in this area to provide greater flexibility. Recruitment practices are adequate, despite a few minor omissions. The home is working to update training needs for staff. A system of staff supervision has been introduced. Quality in this outcome area is adequate. This judgement has been made using all of the available evidence including a site visit to this service. EVIDENCE: The home employs only three staff at the present time all of whom trained as nurses in China. Two staff have worked in the home for approximately 6 months and, since the last inspection, have attended training courses, worked on their English and have developed a good understanding of healthcare systems, recording and reporting. Another member of staff has recently joined the home in the past month and currently works alongside the other team members as part of her induction process. The registered manager reported that he is in the process of receiving confirmation regarding the NVQ level equivalent of the nursing qualifications obtained by staff in China. It would be beneficial for all of the care staff to commence NVQ training with consideration given to enrolling for the Learning Disability Award Framework (LDAF) to further expand knowledge in the area of learning disability care and support and to provide clear competency based training. Refer to recommendation 7. Sea View Lodge DS0000023424.V297534.R01.S.doc Version 5.2 Page 20 In discussion with the two more experienced staff it was evident that adequate levels of competency have been achieved with understanding of the needs of service users and elements of care and protection. The home operates with at least one member of staff on duty at all times. One part-time member of staff has left since the last inspection and a full-time equivalent appointed. Therefore, including the manager, there are periods throughout the week when two staff are on duty. 1 staff member sleeps-in each night. Records demonstrated that there have been no night-time issues or nocturnal variations for service users and it is considered that, with the current numbers and needs of service users staffing levels are adequate. It does need to be stressed however that should more residents move into the home these staffing levels will need to be reviewed. At the present time there is limited flexibility in the staffing arrangements to enable service users to be supported in the community and to engage in supported recreational activities, which is an issue which should remain under review. Staff duty rotas were viewed for the two previous weeks and the current week. The registered manager should ensure that his duty hours are also included on the rota at all times to adequately demonstrate staff on duty. Refer to recommendation 8. Recruitment processes are adequate and the majority of relevant information was retained on file. All documentation relating to the employment of overseas workers appeared to be in place and up to date. A CRB check for one member of staff was yet to be received, but evidence of a POVA check for this individual was on file. Progress has been made in terms of staff training and the registered manager has ensured that staff have begun to commence all mandatory training courses and other training events including adult protection and care planning. All care staff are within their first six months of employment in the home and continuing efforts should be made to ensure all training is provided within this timescale. The home would benefit from introducing competency based induction training in line with the Skills for Care Common Induction Standards. The current induction process is signed off by staff and the registered manager, but does not provide evidence of understanding of topics addressed, additionally some gaps were also noted in the induction checklist sheets. Refer to requirement 2. The registered manager has introduced a system of formal supervision providing staff with 1:1 recorded sessions every two months. This process should be allowed to continue and develop as a two-way process for staff to raise issues and concerns as well as addressing performance issues. All care staff stated that they feel supported by the registered manager and can address any concerns that they have. There is also a good level of peer support evident and a positive working atmosphere. Service users also commented that they like the staff and that they are helpful and supportive. Regular staff meetings have been introduced, although it was noted that the minutes of these meetings are brief and do not provide outcomes and actions, which should be addressed. Refer to recommendation 9. Sea View Lodge DS0000023424.V297534.R01.S.doc Version 5.2 Page 21 Sea View Lodge DS0000023424.V297534.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 42. The health, safety and welfare of service users is promoted and protected. It was not possible to fully assess key standards 37 and 39 due to the absence of the registered manager at the time of the site visit. Quality in this outcome area is adequate. This judgement has been made using all of the available evidence including a site visit to this service. EVIDENCE: Health and safety documentation was reviewed and examined demonstrating that all necessary checks have been completed and maintenance tests carried out. Evidence was available to show that gas safety, electrical and fire records were up to date. Policies and procedures are in place to ensure safe working practices and health and safety issues have been discussed in staff meetings and through supervision. Staff demonstrated adequate competency in the area of health and safety practices. A new accident book has been obtained and environmental and fire risk assessments completed. Work is on-going to install guards for radiators and pipework as per action plan. Sea View Lodge DS0000023424.V297534.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 2 4 X 5 3 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 2 25 X 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 1 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 2 2 3 LIFESTYLES Standard No Score 11 X 12 2 13 3 14 1 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X X X X X X 3 X Sea View Lodge DS0000023424.V297534.R01.S.doc Version 5.2 Page 24 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 YA14 Regulation Requirement Timescale for action 01/09/06 16(2)(m)(n) To provide service users with a range of leisure activities in the home and to reflect this improved choice through appropriate record keeping. 18(1)(c) To introduce competency based induction training in line with the Skills for Care Common Induction Standards ensuring that all areas of the induction programme are covered within allotted timescales. 2. YA35 01/09/06 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. Refer to Standard YA3 YA6 Good Practice Recommendations To provide training for all staff covering care practices for people with learning disabilities. (Recommendation made at previous inspection) To ensure service user plans are reviewed and updated every six months or as the needs of the individual change. DS0000023424.V297534.R01.S.doc Version 5.2 Page 25 Sea View Lodge 3. YA8 To ensure resident meetings are clearly documented showing issues discussed and any outcomes or actions arising from the discussions. To ensure individual risk assessments are reviewed and updated every six months or as the needs of the individual change. To review and introduce available meaningful activities for service users with particular regard to those with reduced levels of mobility. To continue to update the environment as per action plans. To continue to enable staff to undertake relevant NVQ training with consideration given to LDAF. To ensure that the duty rota accurately reflects staff on duty at all times. To ensure staff meeting minutes reflect issues discussed, outcomes and actions. 4. YA9 5. YA12 6. 7. 8. 9. YA24 YA32 YA33 YA36 Sea View Lodge DS0000023424.V297534.R01.S.doc Version 5.2 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. Extracts may not be used or reproduced without the express permission of CSCI Sea View Lodge DS0000023424.V297534.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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