Inspection on 20/12/06 for Seabrook House

This inspection was carried out on 20th December 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Seabrook House 09/03/06

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

CARE HOME ADULTS 18-65 Seabrook House Seabrook House Topsham Road Exeter Devon EX2 7DR Lead Inspector Stephen Spratling Key Unannounced Inspection 20th December 2006 09:10 Seabrook House DS0000066051.V324995.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 Seabrook House DS0000066051.V324995.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. Seabrook House DS0000066051.V324995.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Seabrook House Address Seabrook House Topsham Road Exeter Devon EX2 7DR 01392 873995 01392 877177 seabrookhouse@tiscali.co.uk www.ukhcg.com Seabrook House Limited 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) Mrs Susan May Jenkin Care Home 26 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (26) of places Seabrook House DS0000066051.V324995.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th March 2006 Brief Description of the Service: Seabrook House is registered to provide personal care for up to 26 people who have or have had mental health problems. It is situated on the main road, a regular bus route, from Exeter to Topsham, about ½ mile from the centre of Topsham. Seabrook consists of two separate buildings. One is a large detached converted property with a recently added extension; this building has a variety of accommodation and a ‘training kitchen’. The other building, occupied by more residents, has two lounge areas and a kitchen for residents to use. All the bedrooms are single occupancy and some have ensuite shower and toilet facilities. The home has a large level garden which residents use and help to maintain if they wish. Staff are available in the home 24 hours a day. The current range of fees charged is from £344 to £1706 per week. Copy of the most recent inspection report is available on request from the home manager. Seabrook House DS0000066051.V324995.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Before the inspection site visit the Commission sent out a total of 35 questionnaires, seeking people’s views about the service. Completed or partially completed questionnaires from five service users, four health & social care professionals and five staff were returned. An unannounced visit to the service was made on the 20th December 2006 by one inspector. The site visit lasted about seven and a half hours. During the course of the inspection site visit the inspector spoke with 11 residents; three members of care staff, in private; the home manager; the administrator and the Regional Manager of the company that owns the service. He looked closely at (case tracked) the care of three residents, looked at some records relating to the care of other residents, at some policies and procedures, maintenance records and staff training and recruitment records. During the day all the shared areas of the home were visited and 10 of the private bedrooms. What the service does well: To make sure Seabrook House is the right place for prospective residents, people have opportunity to visit the home and good detailed assessment information is gathered before they are admitted. Once admitted, staff work closely with residents to develop detailed care plans which identify the goals of their stay and how they may be helped to achieve these goals. Residents and community professionals are routinely involved in reviewing and updating care plans. Residents say they are treated with respect, are free to spend time as they choose and benefit from the support they receive to be active and to become more independent. The importance of residents’ personal and family relationships is recognised. Residents generally enjoy the food provided at the home and are provided some opportunity to choose and prepare food they like. Staff are recruited properly, well trained, employed in sufficient numbers and have the qualities and skills they need to be able to care for residents to a high standard. Residents’ comments about staff included “all are very nice” and “there’s always someone around”. Residents can be confident that their complaints and concerns will be listened to and acted upon and that the home is run in their best interests. One resident said “it’s just like a big family here”. Seabrook House DS0000066051.V324995.R01.S.doc Version 5.2 Page 6 The home environment is being improved, is comfortable and is safely maintained. 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. Seabrook House DS0000066051.V324995.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 Seabrook House DS0000066051.V324995.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 Excellent. This judgement has been made using available evidence including a visit to this service. A thorough approach to assessing the needs of potential residents helps to make sure that their needs can and will be met if they move into the home. EVIDENCE: Three files read contained detailed assessments, describing the social and medical histories of the residents concerned. Assessments identified residents’ strengths, needs for support and their personal goals. For example the assessment of a recently admitted resident clearly identified the reason for admission as being to help them develop their self-confidence and skills to live independently. Information identified what the resident had agreed with the home as the areas of personal independence they need to work on. This resident confirmed that they had been included in the assessment and agreed with its content. This service user confirmed that they had visited the home before deciding to move in. Risk assessments were also seen in use to help identify risks as they relate to specific individuals. For example a self harm risk assessment had been done regarding one resident who had a long history of self harm, this assessment described indicators that the resident may be becoming distressed and at heightened risk of self harm. Seabrook House DS0000066051.V324995.R01.S.doc Version 5.2 Page 9 The manager said that before admission to the home, hospital and community staff are asked to complete forms providing assessment information about potential new residents, to complement the home’s own assessments. Evidence that this happens was seen in residents’ files. Seabrook House DS0000066051.V324995.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, and 9 Quality in this outcome area is Excellent. This judgement has been made using available evidence including a visit to this service. Good assessment and care planning practices contribute to ensuring that residents’ needs are met and help them to identify and work towards their personal goals. Residents are free to choose where and how they spend their time, and are supported to develop their capacity for independence. EVIDENCE: All three records seen contained detailed care plans, which reflected the assessments done and residents’ goals. All showed evidence of monthly review; five residents asked said they were aware of their care plans and three confirmed that they take part in reviewing their care plans. Two of the three care staff spoken with confirmed that they are involved in writing and reviewing care plans and both confirmed that residents are always Seabrook House DS0000066051.V324995.R01.S.doc Version 5.2 Page 11 invited to be involved in reviews. The third staff member had been in post for just a few weeks. Care plans provided a good level of description about how the identified needs should be met, describing actions that both staff and residents should take. For example one person’s plan reflected their need for support to maintain their personal hygiene; it focused on encouraging the resident to do things for themselves with the support of staff, rather than simply encouraging staff to do things for/to the resident. A visiting mental health professional wrote on a Commission questionnaire “care planning is completed jointly with residents, staff and myself.” All residents spoken with confirmed that staff treat them respectfully and that while some residents are encouraged to do certain things in line with their care plans, they do not feel forced to do so. Residents spoken with confirmed that they feel free to spend time where and with whom they choose. Staff were aware that they are not entitled to restrain residents in any way, but said they may remind residents of restrictions agreed with them in their care plans. Staff confirmed that they do accompany residents out of the home if they want/need support. Detailed risk assessments were seen in residents’ files. For example an assessment was seen regarding a resident going away from the home for a weekend; this helped to identify the risks of them taking and managing their own medication for this period. It also identified appropriate ‘control measures’ (actions to minimise the risks identified) that staff should put in place, such as observation of behaviour on return and ensuring the resident understood what medication to take and when. Seabrook House DS0000066051.V324995.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from being supported to take part in community-based activities and develop their self-confidence & skills to be independent. The importance of residents’ personal and family relationships is recognised and residents benefit from support to maintain these relationships. Residents are provided with the good food and benefit from being provided with opportunities, resources and support they need to choose and prepare food themselves. EVIDENCE: The home manager reports that residents from the home attend a variety of community based activities including local social clubs, skills training centres, a local garden centre, sports facilities and one resident currently works for a local supermarket. Seabrook House DS0000066051.V324995.R01.S.doc Version 5.2 Page 13 Some residents confirmed that they use these community facilities and that staff are supportive of their attendance. Residents also confirmed that they are encouraged to cook for themselves regularly, manage their own laundry and maintain their own rooms. Within the home residents have access to a pool table and during the summer can work in the garden if they choose. Most residents have TV and music facilities in their own rooms. Care plans described activities that staff should support residents to be involved with; particularly activities focused on promoting residents skills to live independently. Two people’s care plans reflected the importance of supporting the residents to maintain contact with significant family members and one resident spoke about those contacts to the inspector. Residents confirmed that they can see whom they wish and though few have visitors to the home visitors are welcomed. The home’s policy regarding service users’ sexuality and relationships has been updated since the last inspection and is now more supportive of individuals rights to conduct intimate relationships. Of five residents who returned Commission questionnaires which asked “do you like the meals at the home” four answered “usually” and one “sometimes”. All the residents asked said that they like the food provided, confirming that there is always plenty to eat. Menus provided for a four week period show a varied menu. The manager of the home reports that diabetic, soft and low fat diets can be provided if required. In addition to the home’s regular catering kitchen the home has two small domestic type kitchens where residents can prepare food. Many residents have facilities for making hot drinks in their own rooms. Seabrook House DS0000066051.V324995.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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident that they will be treated with respect and that they will receive the help they need to regain/maintain their health and independence. Medications are generally managed safely, though small improvements are needed to ensure that arrangements are fully robust. EVIDENCE: One resident said “staff are nice and treat us with respect”. Others spoken with echoed this view, several were able to confirm that staff consult them about the care and support they want and confirmed that privacy is respected. Of the five service users who returned Commission questionnaires which asked “do staff listen and act on what you say” four answered “yes” and one wrote “sometimes”. Asked “do you receive the medical support you need” all answered “always”. Seabrook House DS0000066051.V324995.R01.S.doc Version 5.2 Page 15 Three GPs and one community psychiatric nurse (CPN) returned Commission questionnaires and all reflected positively on the service provided. Asked “does the home communicate clearly and work in partnership with you” and “do staff take appropriate action when they can no longer manage the care needs of service users” all answered, “yes” to both questions. One person wrote on their questionnaire “residents appear to be respected as individuals by staff generally”. Residents’ records contained information regarding individuals’ physical and mental health, with care plans going on to identify where intervention and/or monitoring was needed. For example one person’s records identified problems they have with ensuring adequate diet; strategies to support them to eat better were described and record of monthly monitoring of their weight was also present. Another person’s file identified that they needed to attend hospital for a routine health screen; the resident confirmed that they had attended the appointment. All four professionals who returned Commission questionnaires responded “yes” to the question “is service users‘ medication appropriately managed…”. The home has appropriately secure storage for medications. Five residents’ medication administration charts seen contained clear record of the medication received into the home and of administration. Staff said that two staff now administer medications to reduce the risk of errors and that those who administer medication must have training first. Training records indicated that seven of the 14 member staff group had attended medication administration training within the preceding nine months. Records for one resident who was starting to manage their own medication showed that they were following a four step program designed to manage risk and gradually increase the level of responsibility the resident takes. No clear assessment of the risks and barriers to this person managing their own medication safely had been recorded before they started on this program. The home’s medication policy provided useful guidance for staff on the safe administration and management of medications, however the guidance about temperatures for cold storage of medications was incorrect and the policy was not adequately clear about how residents wishing to manage their own medication should be assessed as safe (risk assessed) to do so. Seabrook House DS0000066051.V324995.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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident that their complaints and concerns will be listened to and acted upon, and that staff would act appropriately to protect them if they were being abused. EVIDENCE: The manager reported in the pre-inspection questionnaire that five complaints had been received during 2006 and that one had been substantiated. A record of these complaints and the actions taken to investigate was available. The Commission was notified of two of the complaints during the year and the manager demonstrated that they were addressed with an open mind and thoroughly investigated. The home has a clear complaints procedure, though it was not on the home’s notice boards where the manager said it should be for all to refer to. Residents spoken with confirmed that complaints are listened to and acted upon. The two staff asked were clear about the complaints procedure demonstrating clearly that every complaint should be listened to recorded and responded to. Seabrook House DS0000066051.V324995.R01.S.doc Version 5.2 Page 17 Training records indicate that of the 14 care staff, 11 have attended training about how to recognise and report abuse and that nine have received training about how to respond to “challenging behaviour”. Two staff were asked specifically about recognising and reporting abuse and both showed a good awareness of what can constitute abuse and their responsibilities to report any concerns they may have. Seabrook House DS0000066051.V324995.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a much-improved environment for residents to live in which is comfortable and well maintained. EVIDENCE: On the pre-inspection questionnaire the manager reported that two bathrooms have been fully refurbished and another bathroom brought into use for residents. She also reported that six bedrooms, the dining room, lounges and some corridors have been redecorated. During the inspection evidence of this work was clear. The manager said that some residents had declined to have their rooms decorated and this decision was respected as long as their safety was not compromised. One person’s room had been brightly painted to reflect their preference; this person was clearly pleased to have been able to choose the colours for their room. Seabrook House DS0000066051.V324995.R01.S.doc Version 5.2 Page 19 Several areas seen had been re-carpeted though some work remains to be done, for example a landing in the old part of the building still needs decorating and re-carpeting. The manager said that this work was scheduled for the coming three months. Many new furnishings, including some new mattresses were seen. The kitchen has also been completely refurbished and equipped. All areas of the home seen were clean and no unpleasant odours were noticed. Residents asked said that the home is kept clean and that it is well maintained, confirming that they are happy with the accommodation provided. Of the five residents who responded to Commission questionnaires which asked “is the home fresh and clean” one responded “always” and four answered “usually”. The manager reported that the home now has one full time and one part time maintenance staff. A new extractor fan has been installed in the home’s smoking lounge improving the smell and atmosphere in this room. The building exterior and gardens around the building are satisfactorily maintained. All of the residents’ rooms seen were comfortably furnished, many were personalised with residents’ belongings and equipped with TVs, music systems and facilities for making hot drinks. Seabrook House DS0000066051.V324995.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): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Suitably skilled care staff, who receive regular training and are employed in sufficient numbers, help to ensure that residents are treated with respect and get the care and support they want and need. Procedures followed for vetting and recruiting care staff help to protect residents from people unsuitable to care for them. EVIDENCE: All five service users who returned Commission questionnaires responded “yes” when asked “ do staff listen and act on what you say”. All residents spoken with were positive about the staff, offering a variety of comments such as “all (staff) are very nice”, “there’s always someone around” and “it’s just like a big family here”. Seabrook House DS0000066051.V324995.R01.S.doc Version 5.2 Page 21 All four professionals who returned Commission questionnaires responded “yes” when asked “do staff demonstrate a clear understanding of the care needs of service users”. One wrote on the questionnaire “excellent set up with very capable and dedicated staff”. Of the three staff spoken with, one had been in post for about a month and demonstrated that they had started to get to know residents. This person confirmed that they felt well supported and that they were following a structured induction program. They said they had already received basic instruction on health and safety matters, care issues and “managing difficult behaviours”. This person said that they were now enrolled to do their NVQ2 (a nationally recognised care qualification), which was to be paid for by the company. The other two staff members spoken with displayed a clear understanding of residents’ histories, needs and how needs should be met. Both described receiving training about caring for people with mental health problems, which was reflected in how they spoke about the care they offer residents. Both, employed within the past 12 months, confirmed that they had followed a formal induction. The manager said that all new staff follow National Training Organisation common induction programme and an example of this was seen in a staff member’s employment file. The home’s training records show that nine of the 14 care staff have completed or are studying for an NVQ. The records also provide a clear overview of other relevant training which staff have done or are to do, including that 10 have done “mental health specific training” and all others are booked to attend. Three staff recruitment files seen contained all the pre employment information required, such as references and criminal records bureau checks (CRB), to ensure they are suitable people to work in a care home. Seabrook House DS0000066051.V324995.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 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This home is effectively, efficiently and safely managed, in the best interests of residents. EVIDENCE: The home manager is very experienced having worked at this home for many years. She is doing the Registered Managers Award (a nationally recognised qualification) and said she expects to complete it early 2007. She is supported by an administrator and a Regional Manager who is at the home several times a month and who the manager described as “very supportive”. Staff describe the manager and Regional Manager as supportive, approachable and responsive to their ideas and concerns. Seabrook House DS0000066051.V324995.R01.S.doc Version 5.2 Page 23 Over the past year the systems to manage/administer the home have been significantly developed. For example systems for assessing residents’ needs and developing care plans have been improved, with residents and care staff now much more involved in developing and reviewing care plans. Systems for monitoring staff training and ensuring appropriate training is provided have also greatly improved. A comprehensive system for assessing and improving the quality of the service has also been introduced and operates at various levels. For example residents’ views were invited in a questionnaire issued in November 2006, the results had been analysed to identify “areas of concern” and actions taken to address these concerns. One issue identified as an “area of concern” was that some residents felt that meal portions were not always large enough and as a result the manager spoke with the cook and portion sizes for those concerned increased. In addition to this the manager is required to complete a series of monthly audits on issues such as complaints, the environment and training, identifying work done and what needs to be done. These reports are monitored by the Regional Manager who checks that agreed targets, for staff training for example, are being met i.e. training needs are being identified, plans made to provide the training and that staff attended. The staff training record indicates that all staff have received fire safety training within the past six months and that 10 have attended first aid training. Two staff asked confirmed that had recently done fire training and one of them had done first aid training. Maintenance records were seen and included evidence that the fire alarm had been professionally serviced in July 06; fire extinguishers had been serviced in March 06; gas installations were serviced March 06 and the safety of the electrical wiring was checked by an electrician on April 06. A fire exit which goes through a resident’s private room has recently been fitted with a lock which automatically releases if the fire alarm is activated, helping to ensure safety without compromising the privacy of the resident who occupies that room. Seabrook House DS0000066051.V324995.R01.S.doc Version 5.2 Page 24 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 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Seabrook House DS0000066051.V324995.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA20 Good Practice Recommendations Clear procedures for assessing risks related to residents who wish to manage their own medications should be established. Policies should be clear and accurate; medications requiring cold storage should be maintained at between 2 and 8 °C. Seabrook House DS0000066051.V324995.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton Devon TQ13 7UP 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 © 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 Seabrook House DS0000066051.V324995.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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