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Inspection on 19/07/05 for Searchlight Workshops - Webb House

Also see our care home review for Searchlight Workshops - Webb House for more information

This inspection was carried out on 19th July 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Staff were observed to have a good professional rapport with residents and treated them with dignity and respect. Residents choose their own lifestyles and routines of daily living.

What has improved since the last inspection?

Care plans are gradually improving, but there are still some shortfalls. Work is taking place to meet the requirements and recommendations from the last inspection.

What the care home could do better:

There are still shortfalls in the documentation at the home. Despite the home having introduced an internal monthly audit check to ensure correct medication procedures are complied with, there still remains shortfalls in the recording of medication being administered. It is disappointing to note that some requirements are continuing not to be complied with within the set timescales. There is a newly appointed acting manager at the home. Outstanding and newly identified shortfalls should be addressed when the new manager has had an opportunity to familiarise herself with the home and residents.

CARE HOMES FOR OLDER PEOPLE Searchlight Workshops - Webb House Claremont Road Mount Pleasant Newhaven BN9 0NQ Lead Inspector Jennie Williams Unannounced 19 July 2005 9.30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 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 H59-H10 S59528 Webb House V219297 190705 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Searchlight Workshops - Webb House Address Claremont House Mount Pleasant Newhaven East Sussex BN9 0NQ 01273 514007 01273 611289 enquiries@search-light.org.uk Searchlight Workshops Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Vacant Care Home 22 Category(ies) of OP (6) registration, with number PD (16) of places Searchlight Workshops - Webb House H59-H10 S59528 Webb House V219297 190705 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1.That the maximum number of service users to be accommodated is twentytwo (22). 2.That a maximum of six (6) service users accommodated must be older people. 3.That a maximum of sixteen (16) service users accommodated will have a physical disability. 4.That service users with a physical disability may also have a mild learning disability. 5.That service users accommodated are aged fifty-five (55) or over on admission. Date of last inspection 18 January 2005 Brief Description of the Service: Webb House is a care home registered to provide accommodation for a maximum of 22 residents. A recent variation application has been approved to change the conditions of registration. Six places are registered for older people and sixteen places are registered for people with a physical disability who may also have a mild learning disability. Residents must be aged 55 years or over on admission. Webb House is one of the three homes within the Searchlight Workshop group located on 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. 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. 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 ran on site and this opens a couple of evenings a week. The reader should note that there has been a recent change in management and although there are a number of requirements made in this report, the overall outcome for residents is positive. Searchlight Workshops - Webb House H59-H10 S59528 Webb House V219297 190705 stage 4.doc Version 1.30 Page 5 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 unannounced inspection took place over seven and three quarter hours on the 19 July 2005. A tour of the home was not required, as the Inspector had previously inspected the home. Individual rooms were spot-checked. Care plans were spot-checked. Residents, staff and two visiting professionals were spoken with throughout the inspection process. There were 22 residents residing at the home on the day of the inspection. The new acting manager was on a day off. The deputy manager, who has been working at the home for a period of time, facilitated the inspection. What the service does well: 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 H59-H10 S59528 Webb House V219297 190705 stage 4.doc Version 1.30 Page 6 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 Standards Statutory Requirements Identified During the Inspection Searchlight Workshops - Webb House H59-H10 S59528 Webb House V219297 190705 stage 4.doc Version 1.30 Page 7 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 standard(s) 1, 3, 4, 5 & 6 The home has information available to prospective residents and their representatives to make an informed decision if the home is suitable for their needs. All prospective residents are assessed prior to moving into the home. Standard 6 is not applicable, as the home does not have dedicated accommodation to provide intermediate care. EVIDENCE: The home has a Statement of Purpose and Service User Guide that will require amending to reflect the changes in management and the recent changes in the category of registration. A copy of this amended document must be forwarded to CSCI. All prospective residents are assessed prior to admission. The pre assessment form has been amended as required at the last inspection. Prospective residents are encouraged to visit the home prior to moving in. Visitors are welcomed at the home. A resident spoken with confirmed that they were unable to visit the home prior to moving in due to the nature of the admission. Searchlight Workshops - Webb House H59-H10 S59528 Webb House V219297 190705 stage 4.doc Version 1.30 Page 8 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 standard(s) 7, 8, 9 & 10 Needs of residents will be better met when all care plans are reviewed and transferred onto the new format that has recently be developed. Medication procedures need to be greatly improved to safeguard residents. EVIDENCE: Care plans were only spot-checked as it was confirmed that only four to date have been reviewed and transferred onto the new format to cover areas as identified in the last inspection report. The development of the new care plans has been a very slow process. The home must ensure that all care plans are transferred onto the new format by the end of August. This is now an outstanding requirement from the last three inspections. Residents spoken with confirmed that staff discuss their care with them and felt that all their needs are being met at the home. Staff must ensure that all assessment forms that are used for an individual is dated and signed by the person doing the assessment. Some additional risk assessments need to be completed to safeguard staff and the individual. This was discussed with the deputy manager. Areas include: residents having a key to their own room (this remains an outstanding requirement), leaving the Searchlight Workshops - Webb House H59-H10 S59528 Webb House V219297 190705 stage 4.doc Version 1.30 Page 9 home unescorted etc. It is required that risk assessments are reviewed when care plans are reviewed. A risk assessment dated January 2004 was read and there was no evidence that it had been reviewed since. It was confirmed that the new care plan format will cover areas requiring risk assessments. Specialist advice is sought from other health professionals when the need arises. A visiting Speech Therapist was spoken to on the day of the inspection. They had no concerns about the care provided and always found the home clean. It was confirmed that the home will ring them if there are concerns regarding an individuals’ communication or swallowing needs. There is also provision of massages for those residents requiring/wanting this alternative therapy. An external qualified masseuse undertakes massages. It was confirmed to the Inspector by staff and some residents that other residents may on occasion be disruptive and demonstrate signs of mental health issues. The acting manager must ensure these residents’ needs are kept under review, continue to be met and ensure other residents’ lifestyles are not disrupted. There are still shortfalls in the procedure of administration of medication. It was made an immediate requirement that all medications are signed for at the time of administration or reasons provided why it is omitted. There were medications that had been given and not signed for, or medications signed for and not given. There were handwritten amendments on the MAR charts that had not been signed. It is recommended as good practice that all handwritten changes on the MAR charts are signed and double checked by two staff that have been trained in medication procedures. The home needs to update and ensure there is a sample signature obtained from all staff that are responsible for administering medication. As shortfalls had been noted in the organisations other homes, based at the same site, regarding medication issues, all three homes now undertake monthly audits for medication procedures. Residents spoken with confirmed that they felt that their privacy and dignity are respected. Staff were observed to have a good professional rapport with residents. Searchlight Workshops - Webb House H59-H10 S59528 Webb House V219297 190705 stage 4.doc Version 1.30 Page 10 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 standard(s) 12, 13, 14 & 15 Residents are provided with opportunities to fulfil their preferred lifestyles. Contact with families and the local community are encouraged and supported. EVIDENCE: There is a workshop on site that residents of the home can access. This workshop is also available to people within the local community. Most residents spoken with confirmed that they were happy with the activities provided at the home, if they choose to be involved. Any suggestions on changes received from residents were discussed with the deputy manager and responsible individual. Transport is available to the home and residents contribute to fuel costs for outings. Residents are encouraged to maintain contact with their friends and families. Visitors are welcomed at the home and there is a record book that all must sign. Residents spoken with confirmed that they choose their own routines. Bed times are an individuals’ choice. Residents spoken with confirmed that there have been improvements recently in the provision of foods. The home has recently undertaken a survey regarding the provision of meals, due to issues raised within one of the other homes. Residents confirmed that they were all involved in this reviewing process. A copy of the survey and the analysis of the results have been provided to the Inspector. Searchlight Workshops - Webb House H59-H10 S59528 Webb House V219297 190705 stage 4.doc Version 1.30 Page 11 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 standard(s) 16 & 18 There is suitable information provided to enable people involved with the home to make a complaint. There are procedures in place to deal with allegations of abuse. EVIDENCE: Records are kept of complaints that are made to the home. The home needs to ensure that the action taken to resolve a complaint is documented. There have been no complaints made directly to CSCI since the last inspection. The home used to have a copy of the East Sussex Multi-Agency Guidelines for the Protection of Vulnerable Adults, but this is no longer available. It is recommended that the home obtains another copy. It is required that all people left in charge of the home are familiar with the procedures to follow in the case of an allegation of abuse being made. It was confirmed that adult protection issues are covered in the induction programme. Searchlight Workshops - Webb House H59-H10 S59528 Webb House V219297 190705 stage 4.doc Version 1.30 Page 12 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 standard(s) 19, 22, 23, 25 & 26 The location of the home provides opportunities for residents and visitors to access local amenities and transport. Residents live in an environment that suits their needs. EVIDENCE: The home is situated on the top of a hill on the outskirts of Newhaven. The home has access to a mini bus. There are local amenities and access to bus routes at the bottom of the hill. 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. Residents spoken to confirmed that they were happy with their rooms. Rooms that were spot-checked were seen to be personalised to reflect the individual’s choice and personality. A bath was delivering water at around 33°C. All hot water outlets must deliver water around the recommended 43°C. A wooden seat in a shower room had residue stains from mould on it. This requires to be replaced. Searchlight Workshops - Webb House H59-H10 S59528 Webb House V219297 190705 stage 4.doc Version 1.30 Page 13 A resident informed the Inspector that doors are continuing to be slammed, which makes an individual jump. The individual has addressed this with the home, but no improvements have been made. The Inspector had been informed of this at the last inspection. It was explained to the resident that doors must close securely due to health and safety reasons. It was discussed with the deputy manager and the responsible individual that staff must be encouraged to ensure doors are closed quietly to promote the comfort of the residents. One resident who chose to remain in their room, was observed to have been left with the call bell out of reach. It was made an immediate requirement that call bells are accessible to residents at all times. It remains an outstanding recommendation that a grab rail is placed in the corridor on the lower floor. Due to recent changes in category of registration, it is strongly recommended that a qualified Occupational Therapist (OT) assess the home. The Inspector was pleased to observe that the sluice machine has now been relocated to a more suitable location. Laundry is done centrally for all three homes located on the one site and is located away from the home and any areas where food is stored, prepared, cooked or eaten. The home was free from offensive odours on the day of the inspection. Searchlight Workshops - Webb House H59-H10 S59528 Webb House V219297 190705 stage 4.doc Version 1.30 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 & 30 The number and skill mix of staff on duty is meeting residents’ needs. Staff are trained and competent to do their jobs. EVIDENCE: Most residents and staff spoken with confirmed that they felt there were enough staff on duty at all times. Shortfalls occurring in staffing levels are generally due to short notice of staff unable to work due to illness. Residents spoken with were complimentary about the staff working at the home and felt that their needs were being met. All commented that staffing levels have improved since being made a requirement at a previous inspection. A copy of a rolling rota was provided to the Inspector. The rota does not demonstrate what cover is provided at night nor when the acting manager is on a managerial day or working with residents. Staff spoken with confirmed they are provided with training opportunities and are updated on all mandatory training. The Inspector noted that there were mixed feelings about the induction process. One stated it was good and another commented it could have been more structured. It is recommended that the home undertakes a quality monitoring survey with all new staff upon completing the induction process and make adjustments where identified. Two staff files were inspected. One file contained only one reference. All other relevant checks had been undertaken. Any minor shortfalls noted was discussed with the personnel member responsible for recruitment files. All staff files must comply with Schedule 2. Searchlight Workshops - Webb House H59-H10 S59528 Webb House V219297 190705 stage 4.doc Version 1.30 Page 15 There are currently two carers who have achieved NVQ level 3 qualifications and one with NVQ level 2. It was confirmed that there are a further three carers currently undertaking NVQ studies. This requirement has not been reflected as outstanding as it was confirmed that the home is working towards the target date. It is required that the home ensures that the visiting masseuse has an up to date CRB check and POVA check. This was discussed with the visitor at the inspection who is happy to have an update undertaken. Searchlight Workshops - Webb House H59-H10 S59528 Webb House V219297 190705 stage 4.doc Version 1.30 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 35, 36 & 38. Residents are safeguarded by the systems in place to monitor the health, safety and welfare of residents. A developed and implemented quality assurance and quality monitoring programme would enable management to assess the suitably of services provided at the home and identify areas that can be improved. EVIDENCE: Staff spoken with throughout the inspection process were complimentary about the new acting manager in post. They find her approachable and feel comfortable discussing issues with her. Staff and residents were complimentary about management at all levels. It was confirmed that there is still work being done within the organisation to develop an effective quality assurance and quality monitoring system. The Responsible Individual confirmed that this will be completed by the end of July. There are surveys kept at the entrance of the home for people to complete if Searchlight Workshops - Webb House H59-H10 S59528 Webb House V219297 190705 stage 4.doc Version 1.30 Page 17 they wish. Trustees of the organisation undertake monthly unannounced visits to the home to monitor practices and provides a report to the home and CSCI. The organisation has purchased a set of policies and procedures from a company and is currently in the process of personalising them to the home. The Responsible Individual confirmed that this would be completed by the end of July. This is an outstanding requirement from the last two inspections. Between the three Searchlight Workshop homes, individuals’ monies were pooled into the one account. There is evidence that the home is working towards residents having their own accounts as previously required. This will still remain an outstanding requirement. It was confirmed that there is a system being developed to ensure all staff are appropriately supervised. Supervision is not currently being done. One staff spoken with confirmed that they had not had supervision for the past year. The acting manager must make this a priority following her ‘settling in’ period. This remains an outstanding requirement. A manager of one of the other homes is also the designated health and safety officer. It was confirmed that all relevant checks are undertaken and up to date. Staff receive all mandatory training relating to health and safety. Documentation of accidents/incidents requires to be improved and that action identified to be taken is evidenced. One accident report identified that a risk assessment must be undertaken. There was no evidence that the risk assessment was completed. There was a record of an incident where a resident fell and hit their head. There was no record of this in the accident book. There were some power extension leads that were observed to be stretched across the floor. These were inappropriately placed and posed as a trip hazard. Staff must ensure there are no trip hazards within the home. Any changes that may be required must be reported immediately to management. There are designated smoking areas within the home. This must be reinforced to all residents as the Inspector observed an individual smoking in their own room. Any other shortfalls in the health, safety and welfare of residents have been highlighted in the relevant sections of the report. Searchlight Workshops - Webb House H59-H10 S59528 Webb House V219297 190705 stage 4.doc Version 1.30 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x 2 3 x 2 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x 3 2 x 2 1 x 2 Searchlight Workshops - Webb House H59-H10 S59528 Webb House V219297 190705 stage 4.doc Version 1.30 Page 19 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4&5 Schedule 1 Requirement That the Statement of Purpose and Service User Guide is updated to reflect the changes in management and category of registration. A copy of this document is to be forwarded to CSCI. That all care plans are transferred to the new care plan format and covers all areas as stated in NMS 3.3.(Outstanding from last three inspections) That previous and current risk assessments identified are undertaken and reviewed when care plans are reviewed.(Outsatanding from previous inspection) That all assessment forms are dated are signed. That service users demonstrating signs of mental health needs are kept under review and needs continue to be met. That all medications are signed for at the time of administration or reasons given why it is omitted. (Immediate requirement) That an accurate record of medication administered is kept. Timescale for action 30.09.05 2. OP7 15 30.09.05 3. OP7 13.4 30.09.05 4. 5. OP8 OP8 14 14 31.08.05 30.09.05 6. OP9 13.2 19.07.05 7. OP9 13.2 19.07.05 Page 20 Searchlight Workshops - Webb House H59-H10 S59528 Webb House V219297 190705 stage 4.doc Version 1.30 8. 9. OP16 OP18 22.4 & 22.8 13.6 10. 11. 12. 13. 14. 15. 16. 17. OP22 OP25 OP25 OP27 OP28 OP29 OP29 OP33 16.2(c) 13.4(c) 23.1(d) Schedule 4 (7) 18.1 Schedule 2 Schedule 2 24 18. OP35 20.1 19. 20. OP36 OP38 18.2 Schedule 4 (12) 13.4 21. OP38 All medication signed for must be administered. That the action taken to resolve a complaint is documented. That all staff who are left in charge of the home are familiar with the procedure to follow in the case of an allegation of abuse being made. That call bells are accessible to service users at all times. (Immediate requirement) That hot water is delivered around the recommended 43°C. That the wooden seat in a shower room is replaced. That the rota demonstrates what staff work at night and when the manager is on a managerial day. That 50 fo care staff obtain NVQ level 2 or equivalent quanlifications. That staff files comply with Schedule 2. That the visiting masseuse undertakes a CRB and POVA check. That an effective quality assurance and quality monitoring system is developed and implemented. (Outstanding from last two inspections) That arrangements be made to work towards providing individual bank or other savings accounts for service users. (Timscale 31.03.05 not met, see content of report) That all staff are provided with regular supervision. Timescale 31.03.05 not met) That documentation of accidents/incidents be improved and that action identified to be taken is evidenced. That all trip hazards be removed. 30.09.05 30.09.05 19.07.05 31.08.05 30.09.05 31.08.05 31.12.05 30.09.05 30.09.05 31.07.05 30.11.05 30.09.05 30.09.05 31.08.05 Searchlight Workshops - Webb House H59-H10 S59528 Webb House V219297 190705 stage 4.doc Version 1.30 Page 21 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 OP9 Good Practice Recommendations That hand written MAR charts are double checked by another person who is trained in medication adminstration. Any changes written on MAR charts must be signed by the person amending it. That an updated list of staff sample signatures, who are responsible for medication administration, is kept. That the home obtains another copy of the East Sussex Multi-Agency Guidelines for the Protection of Vulnerable Adults. That staff are encouraged to close doors quietly. That the home is assessed by a qualified Occupational Therapist. That a grab rail is placed in the corridor on the lower floor. (Outstanding recommendation) That a survey is undertaken for staff upon completion of the induction process to identify if improvements can be made. That the smoking policy be reiterated to all residents. 2. 3. 4. 5. 6. 7. 8. OP9 OP18 OP19 OP22 OP22 OP30 OP38 Searchlight Workshops - Webb House H59-H10 S59528 Webb House V219297 190705 stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 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 H59-H10 S59528 Webb House V219297 190705 stage 4.doc Version 1.30 Page 23 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!