Inspection on 15/06/06 for Searchlight Workshops - Webb House

This inspection was carried out on 15th 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Searchlight Workshops - Webb... 30/07/07

Searchlight Workshops - Webb... 07/02/06

Searchlight Workshops - Webb... 19/07/05

Searchlight Workshops - Webb... 18/01/05

Searchlight Workshops - Webb... 17/08/04

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Searchlight Workshops - Webb House Claremont Road Mount Pleasant Newhaven East Sussex BN9 0NQ Lead Inspector Jennie Williams Unannounced Inspection 15th June 2006 11:00 X10015.doc Version 1.40 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 Searchlight Workshops - Webb House DS0000059528.V291715.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 Older People. 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. Searchlight Workshops - Webb House DS0000059528.V291715.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Searchlight Workshops - Webb House Address Claremont Road Mount Pleasant Newhaven East Sussex BN9 0NQ 01273 514007 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) Webb@search-light.org.uk Searchlight Workshops Vacant Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (6), Physical disability (16) of places Searchlight Workshops - Webb House DS0000059528.V291715.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. That the maximum number of service users to be accommodated is twenty-two (22). That a maximum of six (6) service users accommodated must be older people, aged sixty-five (65) or over on admission. That a maximum of sixteen (16) service users accommodated will have a physical disability and be aged over fifty-five (55) on admission. That service users with a physical disability may also have a mild learning disability. 7th February 2006 Date of last inspection Brief Description of the Service: Webb House is a care home registered to provide accommodation for a maximum of twenty-two (22) residents. Six (6) places are registered for older people, aged sixty-five (65) years or over on admission. Sixteen (16) places are registered for people with a physical disability who may also have a mild learning disability and must be aged fifty-five (55) years or over on admission. Webb House is one of three homes within the Searchlight Workshop group located at the one site. The home is situated on the top of a hill on the outskirts of Newhaven. There is a mini bus available at the home. There are local amenities and access to bus routes at the bottom of the hill. Unrestricted car parking is available in the adjacent streets. All rooms are for single occupancy and are located over two floors. There is a passenger shaft lift available to assist residents to access all areas of the home. Two of these rooms are provided with en suite facilities. There is a large dining area on the first floor and a good-sized lounge room on the lower floor. There are four bathrooms, of which two have shower facilities and five communal toilets located throughout the home. Some communal facilities and individual rooms have overhead hoist tracking. Grab rails are located throughout the home to assist individuals when mobilising. Any specialist equipment that may be required for an individual will be accessed by the home as the needs arise. There is a workshop on the site available to residents and others within the community. A variety of crafts/activities are offered at the workshop. A social club is run on site and this opens a couple of evenings a week. Searchlight Workshops - Webb House DS0000059528.V291715.R01.S.doc Version 5.2 Page 5 Weekly fees range from £477 through to £791. There are additional costs for hairdressing (£5) and chiropody (£10). Depending on an individuals needs, there are additional cost for activities, papers, holidays, social transport and personalised toiletries. This information was provided to the CSCI on the 10/05/06. Prospective residents know about the home through social service referrals, word of mouth and from living in the Newhaven area. Information about the home can also be obtained from the CSCI website. Searchlight Workshops - Webb House DS0000059528.V291715.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Webb House will be referred to as ‘residents’. This inspection took place over five and a half hours on the 15 June 2006. The Inspector returned to the home for approximately six hours on the 23 June to meet with residents, speak with staff and to assess additional key standards. The Inspector spoke with twelve residents, of both genders and over the age of 55. Ten resident surveys were sent to the home prior to inspection, of which five were returned. Ten relative/visitor comment cards were sent. None of these were returned. One GP and six social worker comment cards were sent. The GP’s was returned and only one social worker completed the survey. Three other social workers contacted the CSCI to advise that they had moved address or no longer had contact with the home and were unable to comment. The Inspector spoke with seven carers, two cleaners, the acting manager, the Responsible Individual, an administrative person and the maintenance person. Ten staff were randomly selected and sent surveys. Two of these were returned. The Inspector did not have any contact with visitors/relatives throughout the inspection. A pre-inspection questionnaire was sent to the home prior to inspection. The environment was looked at and a random selection of individual rooms were viewed. Two new staff files were inspected. One care plan was looked at in detail and specific areas of care were checked in three other care plans. The storing and administration of medication was inspected. A copy of the rota was provided to the Inspector. There were 19 residents living at the home on the day of the inspection. What the service does well: Residents were complimentary about the staff working at the home. Residents’ needs are being met with the skill mix and staffing numbers and facilities provided at the home. Residents/representatives are provided with opportunities to visit the home prior to moving in. Staff were observed to interact well with residents whilst ensuring an individual’s privacy and dignity are respected. Residents’ lifestyle within the home is their own choice and residents are provided with sufficient stimulation to fulfil their interests and needs. The communal environment is generally well maintained and residents are able to personalise their rooms with small items of furniture if they wish. Searchlight Workshops - Webb House DS0000059528.V291715.R01.S.doc Version 5.2 Page 7 All relevant recruitment checks are undertaken on new staff members to safeguard residents. There is an annual quality assurance and quality monitoring system in place to obtain feedback from all people involved with the home, to ensure the home is run in the best interest of residents. Residents’ financial interests are safeguarded. 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. Searchlight Workshops - Webb House DS0000059528.V291715.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Searchlight Workshops - Webb House DS0000059528.V291715.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 & 5 “Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service.” The home has information available to prospective residents and their representatives to make an informed decision if the home is suitable for their needs. EVIDENCE: The home has a Statement of Purpose and Service User Guide that provide prospective residents/representatives information on the care, services and facilities provided at the home. The acting manager undertakes the pre-admission assessment of all prospective residents. There have been no new admissions to the home since the last inspection, so no pre-admission assessments were viewed on this occasion. Information is obtained from other health professionals wherever applicable. Representatives are encouraged to be at the pre-admission assessment, in agreement with the individual. Searchlight Workshops - Webb House DS0000059528.V291715.R01.S.doc Version 5.2 Page 10 The acting manager confirmed that there was no one residing at the home from any minor ethnic community, social/cultural or religious groups with any specific needs or preferences. All three homes located on the one site all became individually registered in March 2004. At the change of registration it was agreed between Searchlight Workshops and the CSCI that those residents already residing at Webb House can remain living there if they choose and as long as their needs continue to be met. Webb House applied for a variation and the above conditions of registration were applied in July 2005. All 19 residents currently residing at the home have a physical disability. It was discussed with the acting manager that all new admissions must be admitted to ensure compliance with the category of registration. Prospective residents are encouraged to visit the home prior to admission to view the home and meet with residents and staff. Most of the residents currently residing at the home have been living at Webb House between two years and 46 years. The home does not have dedicated accommodation to provide intermediate care, however respite is available if there is a spare place. Searchlight Workshops - Webb House DS0000059528.V291715.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 “Quality of this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” There is a risk of some needs not being met due to lack of information recorded in the care plans, however staff demonstrate an understanding of the needs for each resident. EVIDENCE: The acting manager confirmed that the home is going to change the current format for care plans. Care plans in place provide overall general information to staff on how to meet the assessed needs of individuals, however some care plans were not reflecting actual current practice. There were specific needs of an individual’s health that were not reflected in their care plan. One care plan demonstrated that an individual required their blood sugar levels taken daily; records demonstrated that this was not occurring daily. A pressure sore was not reflected in another care plan. Care plans were not thoroughly viewed as the Inspector had a discussion with some staff, who displayed openness and honesty. They confirmed that some medical/health needs of residents were not reflected in the care plans, however they demonstrated an understanding of these needs. Searchlight Workshops - Webb House DS0000059528.V291715.R01.S.doc Version 5.2 Page 12 There was no evidence that care plans were being reviewed on a monthly basis or with the involvement of the individual. Staff write an evaluation sheet on an as and when basis, but confirmed that this is done at least monthly and with the involvement of the individual. This evaluation did not cover all aspects of care for the individual. Some residents spoken with were familiar with their care plan and confirmed that staff discuss their care with them. There is a key worker system in place. It is the key workers responsibility to update care plans. Notes written by staff regarding the care and well being of residents need to be improved. It has been recommended to the acting manager that staff are provided with training on suitable record keeping. Writing ‘nothing out of the ordinary’ or ‘is fine today’ provides the reader with no information on the well being of the individual. Care notes written on individuals do not provide sufficient information to monitor their health. It is important that the mental health status, where applicable, of residents is recorded and provides a clear picture of the status of an individual in order to assist staff in the early detection of behavioural changes and of any deterioration in health. Behavioural charts have been implemented for residents that may require additional monitoring. It was noted that some care notes recorded an accident/incident involving individuals, however there were no accident reports completed. Accident/incident forms and daily notes were not always corresponding. Some risk assessments are in place, however additional work is required to ensure all areas that pose a risk to residents are provided with guidance on how to reduce these risks, such as travelling in the mini bus or self-medication. If a risk is identified as being medium to high, a more detailed risk assessment is completed to clearly identify action to take to minimise these risks. Residents are supported to visit their GP at the surgery. If they are unable to make it to the surgery, the GP will visit the home. Pressure relieving equipment is accessed when the need arises. Specialist health advice is sought when required. There has been a medication room built that provides the staff with a more suitable environment in which to store and handle medication more appropriately. Medication Administration Charts (MAR) inspected demonstrated that medication is being signed for at the time of administration. The home currently does not have any controlled drugs. Hand written amendments and prescriptions are now being appropriately signed as previously recommended. It was noted that creams, eye/ear drops and liquid medications were not being dated when first opened. Risk assessments for those residents who self medicate had not been reviewed since January 2004, despite previous requirements being made. These had Searchlight Workshops - Webb House DS0000059528.V291715.R01.S.doc Version 5.2 Page 13 been implemented by the second day of the inspection. The suitability of these risk assessments was discussed with the deputy manager at the inspection. Of the residents that were asked, all felt that their privacy and dignity are respected. Staff were observed to have a good professional rapport with the residents and were heard to be calling them by their preferred term of address. Residents may arrange a private telephone to be installed into their individual rooms if they wish. Searchlight Workshops - Webb House DS0000059528.V291715.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above 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 “Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service.” Residents’ lifestyle within the home is their own choice and residents are provided with sufficient stimulation to fulfil their interests and needs. EVIDENCE: The majority of residents spoken with confirmed that there were sufficient activities provided should they choose to be involved. There is a workshop on site that was observed to be well used. There is a social club that runs a couple of nights during the week that residents may join. This is also located at the same site as the home. Some residents were going sailing the day after the inspection. On the evening of the first day of the inspection, it was observed that most residents from all three homes at Searchlight Workshops were having a barbecue and watching the World Cup Football on a large screen television. There was a very good-humoured atmosphere amongst staff and residents participating in this event. A shuttle bus has been organised for residents twice a week to go into town with their key workers to do their banking or shopping if needed. This bus is accessible for wheelchair users. There is no charge for activities provided in Searchlight Workshops - Webb House DS0000059528.V291715.R01.S.doc Version 5.2 Page 15 house. Residents contribute towards petrol costs when wanting to go on outings. Outings arranged through the workshop are free. Residents confirmed that their lifestyle within the home is their own choice. Residents were observed to move freely within and out of the home environment. Some staff recently assisted some individuals’ on a holiday to the New Forest area. Those involved spoke very positively about this holiday. It has been discussed with the home that risk assessments should be put in place for residents using the bus to identify if a carer is required to accompany them. If so, the driver who may also be a carer, should not be counted in these numbers. Visitors are welcomed at the home. Residents are encouraged to maintain contact with friends/family and to be involved in the local community. There is a visitor’s book at the entrance of the home that all people must sign when entering and leaving the home. Food is currently being provided from a central kitchen that supplies residents residing at the homes located on the one site. Most residents were complimentary about the food being provided at the home. All confirmed that they have a choice in food. Any minor concerns expressed by individuals were addressed with the home on the day of the inspection. There is currently an industrial kitchen being built within Webb House. It was discussed with the acting manager and Responsible Individual that residents residing at Webb House are provided with an opportunity to assist in devising a menu, should they wish. Meals provided at this home should be catered towards the needs of the residents residing at Webb House. The needs of diabetics and other specialist dietary requirement need to be taken into account when devising these new menus. Searchlight Workshops - Webb House DS0000059528.V291715.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 “Quality of this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” Residents feel comfortable to complain and feel that their concerns will be acted on. Written procedures for the Protection of Vulnerable Adults were not available, however staff demonstrated an understanding of the procedures that must be followed to ensure the safety of residents. EVIDENCE: The home has a complaints procedure in place. Of the residents that were asked all confirmed that they know who to speak to if they were unhappy about anything. Residents surveys received demonstrated that three out of five residents know how to make a complaint. There have been no complaints made to the home or directly to the CSCI since the last inspection. The Inspector requested a copy of the adult protection policy to be forwarded on to the CSCI. This has not been received at the time of writing this report, so the suitability of the policies and procedures in place for dealing with Protection of Vulnerable Adults (POVA) cannot be assessed. Some staff spoken with confirmed that they have received POVA training and are familiar with the procedures to take in the event of an allegation being made. Searchlight Workshops - Webb House DS0000059528.V291715.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 & 26 “Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service.” Residents live in a clean and homely environment and are provided with comfortable indoor and outdoor communal facilities. EVIDENCE: The environment at Webb House is currently undergoing changes. A visitor’s toilet has been adapted into a medication room, one resident toilet has become the staffs’ toilet, a residents bathroom has been changed to a residents toilet facility and a new industrial kitchen is being built on site which resulted in a bedroom decreasing in size and losing the en suite facilities. It was discussed with the acting manager and Responsible Individual that this room will only be suitable for an older person and not suitable for wheelchair users. On discussion with staff and residents it became apparent that the implementation of these building works were not managed in the best way. The staff and the Inspector had to use staff toilets at one of the homes over the road. Staff confirmed that this practice had been for two months, due to Searchlight Workshops - Webb House DS0000059528.V291715.R01.S.doc Version 5.2 Page 18 the medication room being built prior to another staff facility being provided. Steps should be taken to ensure that the staff toilet can be locked and only used by themselves, as expressed by some staff members. The building of the kitchen should be completed within the next month. This has been very disruptive for staff and residents and they all should be complimented on the patience they have demonstrated during this difficult period. Residents have a small kitchen that they are able to use, however due to the dishwasher having to be relocated temporarily into this facility; wheelchair residents are now unable to use this kitchen. The cooking classes that had been commenced have temporarily been suspended due to this lack of accessibility. Individual rooms were seen to be personalised to reflect the individuals’ choice and character. Residents spoken with were happy with their rooms. Some radiators were noted to have been guarded and the maintenance person confirmed that the radiators unguarded are of low surface temperatures. Some hot water pipe work was noted to be uncovered. This was pointed out to the maintenance person who will ensure these pipes are covered. Hot water is regularly checked. Areas tested demonstrated that hot water is being delivered around the recommended 43°C. The home was clean and free from offensive odours on the day of the inspection. The two cleaners spoken with confirmed that they are provided with sufficient time and equipment to undertake their duties. There is a central laundry that provides a service for all three homes. Searchlight Workshops - Webb House DS0000059528.V291715.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 “Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service.” Residents’ needs are being met with the skill mix and numbers of staff on duty and are safeguarded by the robust recruitment procedures in place. EVIDENCE: Residents spoken with were generally complimentary about the staff working at the home and felt that there were sufficient numbers of staff on duty. Staff spoken with also confirmed that they felt there were generally enough staff on duty. The rota provided to the inspector demonstrates that there is generally five staff working in the mornings, four in the afternoons. There is one waking carer and one sleep in worker for the night duties. The home is working towards the ratio of 50 of staff being NVQ level 2 or equivalent qualified. There are currently four out of sixteen carers with NVQ level 2 or above. Two carers are currently undertaking NVQ level 2, two doing NVQ level 3 and one staff member completing their NVQ level 4 qualifications. The home has a suitable recruitment system in place and all relevant checks are undertaken prior to a person commencing employment. This includes suitable references being obtained, a POVA check and an enhanced CRB being completed. A manager of another home within Searchlight Workshops maintains the training schedules for all staff within the three homes. She will send training Searchlight Workshops - Webb House DS0000059528.V291715.R01.S.doc Version 5.2 Page 20 schedules to the acting manager to notify the staff when training is being provided. Staff spoken with confirmed they are kept up-to-date with mandatory training and are provided with plenty of opportunities to attend training sessions that are relevant to their roles. Some residents are diabetic and some staff feel that it would be beneficial if they were provided with training in relation to diabetes. New staff are provided with induction files that must be completed. It was confirmed that these cover all Foundation Standards and comply with the TOPSS specifications. Searchlight Workshops - Webb House DS0000059528.V291715.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 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, 33, 35, 36 & 38 “Quality of this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” The home is generally run in the best interest of residents. Residents’ financial interests are safeguarded. Additional work needs to be undertaken to continue to promote the health, safety and welfare of residents and staff. EVIDENCE: The acting manager has been in post for nearly a year and must prioritise on returning an application form to the CSCI to begin the registration process. She has worked within the care industry for a period of time in a variety of roles, predominantly working with people that have learning disabilities. She is currently completing NVQ level 4 in Health and Social Care and is planning to commence the Registered Manager Award (RMA). Staff spoken with generally find the acting manager supportive and approachable. Searchlight Workshops - Webb House DS0000059528.V291715.R01.S.doc Version 5.2 Page 22 There is a designated person within Searchlight Workshops who has taken on the responsibility of implementing the quality assurance and quality monitoring on an annual basis. It was confirmed that surveys were about to be sent out again. Feedback is sought from residents, relatives, GP’s, Dentists, District Nurses and Social Workers. No additional surveys have been completed since the last inspection at which the results proved positive. It is proposed that surveys will be sent out on an annual basis. All residents at Webb House are now provided with their own bank accounts. Residents are provided with lockable facilities within their own rooms for safe storage of monies/belongings. Residents are assisted in procedures for managing and budgeting their own finances. Staff spoken with confirmed that they are provided with supervision every two to three months. Staff surveys received also demonstrated that regular supervision is being provided. A manager of one of the other homes was the designated health and safety officer. This responsibility is now being put back to each individual home. Relevant training is being provided to the senior people who will be responsible to ensure the residents and staff remain in a safe and well-maintained environment. The pre-inspection questionnaire received demonstrates that all relevant health and safety checks are undertaken. It was confirmed that there is always a designated first aider on every shift. There are designated smoking areas with the home and it was noted that some individuals’ are smoking in their own rooms. It is important that steps are implemented to monitor the number of burn holes in an individual’s room. Staff receive fire training and regular fire drills are undertaken. As mentioned previously, it was noted that some accidents occurring were not being recorded on the appropriate accident forms. It was also discussed with the acting manager prior to inspection that Regulation 37 reports are sent to the CSCI. It was noted that in the last 12 months there were sixteen admissions to Accident and Emergency. CSCI needs to be informed of these incidents. Searchlight Workshops - Webb House DS0000059528.V291715.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 Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X 2 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 2 Searchlight Workshops - Webb House DS0000059528.V291715.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES 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 OP7 Regulation 15 Requirement That care plans reflect actual current practice and that evidence be provided that they are reviewed with the service user. That risk assessments are implemented for all activities of daily living that may pose a risk to an individual. That daily records about service users are expanded; ensuring mental health needs are reflected when applicable. To ensure any self-medication in the home is managed under a risk assessment basis and kept under review. (Timescale 31/03/06 not met) To provide service users with an opportunity to input into the development of a menu. That a copy of the Protection of Vulnerable Adults procedure is forwarded to the CSCI. That hot water pipes are guarded. That documentation of accidents/incidents be improved. (Outstanding from last two DS0000059528.V291715.R01.S.doc Timescale for action 31/08/06 2. OP7 13.4 31/08/06 3. OP7 Schedule 3 (k) 13(2) 31/08/06 4. OP9 31/07/06 5. 6. 7. 8. OP15 OP18 OP25 OP38 12(2) 13(6) 13(4) Schedule 4 (12) 15/08/06 31/08/06 31/08/06 31/08/06 Searchlight Workshops - Webb House Version 5.2 Page 25 9. OP38 13.4 10. OP38 37 inspections) That steps are implemented to monitor the number of burn holes in a smokers room and a risk assessment be implemented. (Timescale 08.02.06 not met) That all relevant Regulation 37 reports are forwarded to the CSCI. 31/07/06 31/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP7 OP9 OP22 OP31 Good Practice Recommendations That staff are provided with training on record keeping. That topical medication in use is dated when first opened for use. That the home be assessed by a qualified Occupational Therapist. (Outstanding recommendation) That an application be forwarded to the CSCI to for a registered manager. Searchlight Workshops - Webb House DS0000059528.V291715.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Searchlight Workshops - Webb House DS0000059528.V291715.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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