Inspection on 22/02/07 for Sevenoaks

This inspection was carried out on 22nd February 2007.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sevenoaks 11/02/09

Sevenoaks 22/03/06

Sevenoaks 16/08/05

Sevenoaks 15/02/05

Sevenoaks 01/12/04

Sevenoaks 16/02/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Sevenoaks Lords Hill Coleford Glos GL16 8BG Lead Inspector Mr Nick Jones Key Unannounced Inspection 22nd February 2007 10:00 Sevenoaks DS0000016575.V328668.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 Sevenoaks DS0000016575.V328668.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. Sevenoaks DS0000016575.V328668.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sevenoaks Address Lords Hill Coleford Glos GL16 8BG 01594 832679 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) The Orchard Trust Mrs Elizabeth Jones Care Home 10 Category(ies) of Learning disability (11), Sensory impairment (5) registration, with number of places Sevenoaks DS0000016575.V328668.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd March 2006 Brief Description of the Service: Sevenoaks is a modern detached split-level bungalow situated within half a mile of Coleford Town Centre in the Forest of Dean. The home accommodates up to ten people with learning disabilities, five of whom may have a sensory impairment. The accommodation comprises of 10 single bedrooms, six of which have en-suite facilities. The home currently has a vacancy. The house is separated into two wings, known as Phase 1 and Phase 2. Each has its own separate dining and lounge areas, kitchen, offices and communal bathrooms. The original home retains sleeping-in facilities for staff and a small laundry. The newer home has a larger laundry. At the rear of the property there is a parking area and landscaped garden. Residents have access to three vehicles. The home is part of the Orchard Trust group. Prospective service users and others involved in their care are offered information about the home including copies of the Statement of Purpose and Service Users Guide. This has just been updated and will be produced in symbol format in due course. Weekly fees charged for the service range from £743 to £1929 per week. Sevenoaks DS0000016575.V328668.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection began on the 22nd February in the afternoon for about five and a half hours. A second visit was made the following week from morning through to the early afternoon. All of the service users were met, along with many of the staff team. The manager was present on both days. Before the visit a pre-inspection questionnaire was returned. Feedback was also obtained through staff, health care professionals and service user surveys. During the visits to the home various documents were checked including examples of care plans, risk assessments, medication charts, daily records, health and safety records and staffing files. Some general observation of life in the home took place and the premises were inspected. What the service does well: The manager and staff team are committed to providing a person centred approach to meet the needs of service users. They provide a flexible service that recognises the wide variety of support needs of service users. Care plans and risk assessments provide detailed information as to how people should be supported. Discussions with staff showed that staff have a good knowledge of these support needs. Staff are skilled at communicating with service users and at recognising their wishes and feelings. A pleasant, tactile and stimulating environment is provided for service users, particularly those with sensory deprivations. The staff work well with other professionals to ensure the personal and healthcare needs of individuals are met. Staff report that they enjoy working at the home and get the support and assistance they require at all times. Staff receive a comprehensive induction and appropriate on-going training including NVQ qualifications. Sevenoaks DS0000016575.V328668.R01.S.doc Version 5.2 Page 6 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. Sevenoaks DS0000016575.V328668.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 Sevenoaks DS0000016575.V328668.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): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The information provided by the home enables prospective service users/relatives/sponsors to make an informed choice. Good arrangements are in place around referrals and admissions, increasing the likelihood that appropriate admissions will be made. EVIDENCE: The home has a Statement of Purpose and a Service User Guide. This provides considerable information about the home and would assist someone who was considering living there. It was produced in May 2006. It still makes reference to the NCSC rather than the CSCI. However work has taken place across the Trust to produce an updated format for all of the registered services that will then be adapted for each individual service. It is detailed and comprehensive with all relevant information updated. It was recommended that details of any communal areas of the home that are kept locked, such as the kitchen and laundry, are detailed and the reasons why it is necessary. The registered manager of the home would formally assess any prospective service user. The home has an appropriate assessment tool available for use. The home has not had any new admissions during the previous year since. Sevenoaks DS0000016575.V328668.R01.S.doc Version 5.2 Page 9 Placing authorities reviewed the needs of all service users during October and November 2006. Sevenoaks DS0000016575.V328668.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 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good arrangements are in place around care planning that promotes consistency and best practice. People’s choices are ascertained and respected as far as possible, helping to empower service users to take control of their lives. Arrangements are in place to assess and manage risks, promoting service users’ safety with minimal restrictions and limitations. EVIDENCE: The care plans of five service users were viewed, three in more detail as part of case tracking. The plans were detailed and clearly written. They indicated the needs, interventions and desired outcomes for service users. The care plans indicated the relevant issues under each section and included support needs such as personal care, mobility, support routines at different times of Sevenoaks DS0000016575.V328668.R01.S.doc Version 5.2 Page 11 day, communication, staff responses to conflict situations, sensory deprivation support needs, leisure and daytime pursuits, health support needs and eating and drinking. One of the plans was written up in the form of a ‘Person Centred Plan’. This format includes a section titled ‘What you need to know to successfully support me’ which contained clearly written information for staff to read. The manager stated this format was in the process of being introduced for all service users living at the home. One care plan had post it notes attached describing amendments needed to the care plan. Some entries and documents in personal files were not signed or dated. Care plans showed the service was sensitive to the needs of service users in terms of their ethnic background and range of disabilities. There was evidence that care plans and risk assessments were regularly reviewed and amended if the needs of a person had changed. Health clinicians were involved in these reviews. Discussions with staff and observations of staff interactions with service users over the two days demonstrated that staff have a good understanding of the support and communication needs of service users. Viewing care plans and risk assessments and spending time with service users demonstrated they are imaginatively supported to make choices and decisions in their day-to-day lives. Staff were clear that service users were able to make their own decisions as much as possible. Service users were observed to make choices about where they spent time and with whom. Local CLDT (Community Learning Disability Team) clinicians have supported the staff team in devising communication plans for people who do not use language or sign language to communicate. Staff were able to explain the use of specific signs, objects of reference, photographs and symbols to aid communication with service users. Any limitations to choice are documented. Best interest forms were viewed in service user’s files that described in detail the reasons for the limitation to choice. There was evidence that CLDT clinicians have been involved in assessments of any limitations to choice by service users. There was evidence that a recent referral had been made to the CLDT to assess how best to support a service user with behaviour that may have a negative impact on other service users. Risk assessments are in place identifying hazards and how these are to be minimised. Activities included use of a vehicle, being alone in a bedroom, eating and drinking, staff support of self-injury and personal care, swimming and the use of a kettle. These records were being reviewed and amended in response to changing needs. Sevenoaks DS0000016575.V328668.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): 12,13,14,15,16 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users enjoy a variety of activities within the local community and friends and family are welcomed. People have individual interest and routines that are accommodated and respected. A varied and healthy diet supports service users to lead active lifestyles. EVIDENCE: People living at the home have a range of educational, social and leisure activities. The programme for each service user was contained in their personal files. Some attend the Barn, which is owned by The Orchard Trust, and run in conjunction with Gloscat. Others attend the local College and other day centres. Other activities include shopping, swimming, hydrotherapy, music therapy, bingo, trampolining, attending music and theatre shows, attending the ‘Triangle’ social club, walking, visits to cafes and pubs, and other excursions. Sevenoaks DS0000016575.V328668.R01.S.doc Version 5.2 Page 13 Daily notes were being written which described activities undertaken by service users including involvement in domestic activities. . Service users were also seen to be involved in household routines where possible, such as recycling and putting out the bins. The home has a range of entertainment equipment, interactive and sensory equipment that can be used in a group or with individuals. Staff were observed spending time with individuals in a variety of ways which gave the environment a lively relaxing feel to it. The people observed appeared to be happy and relaxed in their interactions with staff. Staff were observed to support service users to be able to listen to music, play on a electric keyboard or watch television when they indicated this choice. Service users are offered holidays that meet their individual needs and wishes. This included a holiday to bungalow in Devon and an outward bounds holiday venue. Social and family relationships are encouraged and supported and most service users have contact with family/friends. The home has worked positively to foster an increase in family contact for some service users. Staff place great emphasis on ensuring the food likes/dislikes of service users are known and responded to. Records of people’s likes/dislikes are kept. A member of staff described being able to involve two service users in choosing meals for menus in using pictures in cookbooks. The three-week rolling menu has recently been revised to take into account the preferences of service users. The menus provide a varied, nutritious and balanced diet. Discussions with staff and observing lunchtime showed service users are able to eat meals either communally or alone if this is their preference. Meals are prepared for individuals depending on their individual specialist diets and around their commitments at lunchtime. What is eaten is recorded for the individual. The dietician is involved with some of the people living at the home. Records of food and fluid intake are recorded in more detail where care plans identify a health need to record this information. Sevenoaks DS0000016575.V328668.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, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The support and guidance offered to service users by staff and health professionals ensure personal care and health care is adequately provided. The procedures for the prescribing, storage and administration of medicines ensures the health and welfare of service users is maintained. EVIDENCE: Care plans provided detailed guidance about how people’s personal care needs were to be met. These included moving and handling plans for some service users. They provided details about any specialist skin/hair care products required by a service user. Staff were seen offering personal care support in a sensitive manner. Staff spoken with described how they met personal care needs in ways that respected people’s preferences, privacy and dignity. Sevenoaks DS0000016575.V328668.R01.S.doc Version 5.2 Page 15 Healthcare notes for three people were looked at in detail. These included evidence that people were accessing a wide variety of routine and specialist services according to their individual needs. Records showed that ‘health action planning’ has started to be introduced that include an annual health check with the service user’s GP. Recommendations from health professionals such as a community nurse and a dietician are implemented appropriately. There was evidence that service users are provided with regular health checks and that medical interventions with conditions such as epilepsy are implemented appropriately by staff. The prescribing of medicines was also seen to be have been reviewed with the involvement of GPs or a consultant psychiatrist. The health records of one service user indicated an appointment was due to be booked regarding their epilepsy. There were no records of this appointment or any results from it. The manager was able to locate a letter from the CLDT clinician involved in her own filing cabinet. It provided details of the need to amend the person’s medication and the reasons for this. Staff administer medicines and there was a record of the receipt, administration and disposal of prescribed medicines. All were accurate and up to date. All administration of medicines was double checked and signed by staff. Medicines were being stored appropriately. Staff have received training in the safe handling of medicines. Sevenoaks DS0000016575.V328668.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 with one aspect being considered adequate. This judgement has been made using available evidence including a visit to this service. Arrangements are in place for managing complaints that ensures service users have an active voice. Systems are in place, in the main, that help to protect service users from harm and abuse. EVIDENCE: Service users are limited in their ability to verbally comment on matters, which affect them. Staff spoken with were able to describe in detail how people living in the home expressed dissatisfaction and unhappiness, and talked through how they responded, giving examples. This sensitivity was observed during the inspection. There have been two complaints received by the home since the previous inspection. The manager described actions taken by the home and provided documents recording the complaint and how the home responded. The responses were appropriate and resolved issues raised in the complaint. Team meeting minutes showed the staff team discuss how to meet the needs of service users on an on-going basis. All staff have completed or are booked on Adult Protection and ‘Whistle blowing’ procedures training courses. Staff spoken with demonstrated an understanding of abuse and the indicators that it may be taking place, along with their responsibilities if they were concerned about something. They expressed confidence in the arrangements for reporting and investigating concerns. Sevenoaks DS0000016575.V328668.R01.S.doc Version 5.2 Page 17 The manager stated that staff very rarely use Physical Intervention when supporting service users with challenging behaviour. This was confirmed when viewing service user’s files. They attend training in the management of challenging behaviour by a trainer accredited with BILD. This focuses on diversion, de-escalation and distraction. Training records showed that several staff have either not received the training or require a refresher course. Sevenoaks DS0000016575.V328668.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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A clean, homely and comfortable environment, in the main, is provided, promoting service users’ quality of life. EVIDENCE: All communal areas and all of the occupied bedrooms were checked during the inspection. Sevenoaks was seen to be homely and comfortable throughout, with service users’ rooms being attractively decorated and personalised. There was evidence that key workers have been adding various sensory objects to service users’ rooms that will enhance the stimulation available to service users in their rooms. Sevenoaks has an ongoing programme of decoration and replacement of furniture. All the required furnishings are supplied in the home as appropriate. There were plans to improve the outside appearance of the home, to include the replacement of fencing. Each person staying at the home has their own Sevenoaks DS0000016575.V328668.R01.S.doc Version 5.2 Page 19 room with en-suite facilities and access to nearby bath/shower rooms, which are appropriately equipped. A range of specialist adaptations and equipment are provided for the people living at the home that are specific for this particular client group. The home has regular contact with the Physiotherapist and Occupational Therapist to ensure that as needs change the equipment available continues to meet the needs of the individuals and the staff caring for them. The home was found to be clean and hygienic. Staff have access to disposable gloves, aprons and laundry bags. Sevenoaks DS0000016575.V328668.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): 32,33,34,35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Support is provided by a skilled, well-trained and supervised staff team, helping to ensure that service users’ needs are met. The manager has a sound understanding of recruitment and selection ensuring service users are protected. EVIDENCE: The inspector was able to watch many interactions between staff and service users, and the view was that staff were attentive, competent and caring and placed the needs of the service users as paramount. Service user files viewed showed the home is well supported by outside professionals such as clinicians from the CLDT. The Trust employs two NVQ assessors and the manager is also an NVQ assessor. Seven staff are undertaking an NVQ 2 in health and social care with three staff completing the NVQ 3. Sevenoaks DS0000016575.V328668.R01.S.doc Version 5.2 Page 21 On the day of the inspection, there were nine people living at the home. There were four staff working in ‘phase 2’ and two staff working in ‘phase 1’. Duty rotas showed that the levels vary between three and four staff in ‘phase 2’ and two to three staff in ‘phase 1’. Domestic staff and a handyman also work at the home. The manager and deputy manager usually work from Monday to Friday. These staffing levels appeared adequate for the present resident group even though staff also deal with catering duties. There have been two staff on long-term sick leave which the manager acknowledged has sometimes impacted on being able to undertake activities away from the home. Shifts were being covered by existing staff, locum staff and very occasionally agency staff. The manager described the steps that she takes when recruiting staff, demonstrating a sound awareness of the relevant National Minimum Standards and Care Homes Regulations. Three files of newly recruited staff were viewed. They contained most of the details as required under Schedule 2. The human resources employees are based the Trust’s office and keep copies of both the PoVA First e-mail print out and the CRB clearance document. The files in the home usually contain details of the CRB clearance number and the date of the PoVA First check. The previous report stated that when PoVA First information comes through on the email it must always be printed off as evidence and put on the individual personnel file in the home. The manager and human resources staff agreed that the PoVA e-mail received by the human resources staff would be forwarded to the manager to be printed off at the home. One file did not include details of a PoVA First and CRB checks. They were available for viewing at the Trust’s office. Discussions with staff and the manager, and viewing staff records showed new staff were being provided with comprehensive induction and training. Staff receive both the in-house induction as well as undertaking the LDAF (Learning Disability Award Framework) induction. Staff described being provided with supervision during the induction by both senior staff from the Trust as well as managers at the home. They also described reading care plans and working along side experienced staff as part of their induction. Staff receive training in any manual handling procedures within the first three days of commencing in post. This is provided by a senior carer who is a trained trainer in moving and handling. A detailed training matrix was being maintained to enable the manager to know the training staff have undertaken or booked to do. This showed that ‘mandatory’ training was generally either booked or had taken place. Staff described attending course that addressed the specific to the needs of people living at the home. This included courses on visual impairment, autism and epilepsy. There was evidence that some staff have attended a BILD (British Institute of Learning Disabilities) – accredited course in physical intervention. Records showed that a good number of staff required this training or a refresher Sevenoaks DS0000016575.V328668.R01.S.doc Version 5.2 Page 22 course. The manager stated a course was booked for May 2007 but it is a requirement of this report that all staff that require this training will attend the course. Discussions with staff and viewing staff supervision records demonstrated that they were being offered good support that included recorded supervision sessions. However some staff records showed that the frequency of these sessions was less than the six times a year, as outlined in Standard 36.4. One staff member commented that the managers at the home have an open door policy and has always felt able to discuss issues if they wished. Sevenoaks DS0000016575.V328668.R01.S.doc Version 5.2 Page 23 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, 38, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run, promoting positive outcomes for service users. Systems are in place that help to monitor and improve the quality of the service provided. Systems are in place enabling the home to provide an environment that promotes the welfare and safety of people living there. EVIDENCE: The home is managed by the Registered Manager, with support from a Deputy Manager. The manager is an experienced manager and has an NVQ Registered Managers Award at Level 4. She is also an NVQ assessor. Sevenoaks DS0000016575.V328668.R01.S.doc Version 5.2 Page 24 The manager stated she would be attending a course on Equality and Diversity that may be provided for other staff at the home. Staff surveys and discussions with staff confirmed that the management approach of the home is open and positive. Team meeting minutes contained details of wide ranging discussions about service users and the running of the home. A senior manager usually spends two days a week at the home and completes monthly Regulation 26 visits. Copies of these were available for inspection at the home. Feedback forms were sent out in July 2006 to relatives to gain their views on the service provided to their relative. Two were positive about the quality of life provided to their relative, with one highlighting problems with communication between them and the home. The manager described steps taken by the home to improve this aspect of the service. The comment cards from relatives returned to the Commission were all positive the service provided, with one exception. Health and safety aspects of service provision were being maintained and monitored. Comprehensive records viewed included fire safety checks, water temperatures, various health and safety checks/assessments and servicing of equipment. Audits of any accidents or incidents were being undertaken to help prevent similar incidents in the future. A new Fire Safety risk assessment has been produced in October 2006, in line with recent changes to fire safety legislation. It was recommended that the home contact the Gloucestershire Fire and Rescue Service to confirm arrangements for evacuation in the event of a fire to meet the requirements of the new Evacuation Strategy. Records showed there had been gaps in recording weekly fire alarm tests. The manager stated this duty had been allocated to the domestic member of staff, as they would be able to complete this task on the same day every week. It is a requirement of this report that these checks take place regularly and a record kept of them. Sevenoaks DS0000016575.V328668.R01.S.doc Version 5.2 Page 25 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 3 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 3 34 2 35 2 36 2 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 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 2 X Sevenoaks DS0000016575.V328668.R01.S.doc Version 5.2 Page 26 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 YA34 Regulation 19(1)Sch 2.7 Requirement Timescale for action 31/05/07 2. 3. YA35 YA43 When PoVA First information comes through on the email it must always be printed off as evidence and put on the individual personnel file in the home. (Timescale of 31/05/06 not met) 18 (c ) (i) BILD-accredited physical intervention training must be provided for all staff. 23(4) ( c ) Weekly fire alarm checks must be undertaken and a record of them maintained. 30/06/07 31/05/07 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 YA1 Good Practice Recommendations The Statement of Purpose and Service User Guide should describe details of any communal areas of the home that are kept locked, such as the kitchen and laundry, are detailed and the reasons why it is necessary. Care plan amendments should be completed, signed and dated. DS0000016575.V328668.R01.S.doc Version 5.2 Page 27 2. YA6 Sevenoaks 3. 4. 5. YA19 YA19 YA43 Records of health appointments and outcomes/recommendations should be maintained in service users’ files Health action plans should be introduced for all service users. The home contact the Gloucestershire Fire and Rescue Service to confirm arrangements for evacuation in the event of a fire to meet the requirements of the new Evacuation Strategy Sevenoaks DS0000016575.V328668.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Sevenoaks DS0000016575.V328668.R01.S.doc Version 5.2 Page 29 - 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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