Inspection on 05/07/07 for Sharpe House

This inspection was carried out on 5th July 2007.

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

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

Other inspections for this house

Sharpe House 24/06/09

Sharpe House 11/07/06

Sharpe House 24/11/05

Sharpe House 09/06/05

Sharpe House 22/06/04

Similar services:

The Vicarage

St George`s

Credence House

Radfords

Honeybourne House

Stallcombe House

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

CARE HOME ADULTS 18-65 Sharpe House 1 West Road Wiveliscombe Somerset TA4 2JS Lead Inspector Kathy McCluskey Unannounced Inspection 5th July 2007 09:30 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 Sharpe House DS0000046271.V338274.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. Sharpe House DS0000046271.V338274.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sharpe House Address 1 West Road Wiveliscombe Somerset TA4 2JS 01984 629220 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) jeddinternational@yahoo.co.uk Jedd International Ltd. Post vacant Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Sharpe House DS0000046271.V338274.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th July 2006 Brief Description of the Service: The home is located in the small town of Wiveliscombe and is situated a short walk from the local community and its facilities. Sharpe House is a large detached property arranged over two floors. The layout of the home would not be suitable for service users with a physical disability. All bedrooms are single and have hand wash basins. Some bedrooms are located on the ground floor. The home does not have a passenger lift to reach the first floor. The home has dining room, lounge, conservatory, and two bathrooms, domestic style kitchen, laundry room and well-presented garden. Sharpe House is registered with the Commission for Social Care Inspection to provide personal care for up to 10 service users, under the age of 65yrs, who have a learning disability. The home is not registered to provide nursing care. The home is owned by JEDD International Ltd. The Registered Provider is Mr Declan Howlett. The registered manager post is currently vacant since the end of June 2007. The home’s current fee range is £330-£805 per week. Additional charges include those for toiletries, hairdressing, transport some activities and chiropody. The home has two cars and service users currently contribute 50 of their DLA mobility component towards the cost of transport. Sharpe House DS0000046271.V338274.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of this inspection visit was to inspect relevant key standards under the Commission’s ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are; - excellent, good, adequate and poor. This key unannounced inspection was conducted over one day by CSCI regulation inspector Kathy McCluskey. The registered manager has recently left his post and the deputy manager was not available for this inspection. The inspector was able to speak with the registered provider on the telephone. Two members of staff were available throughout this inspection. At the time of this inspection nine service users were living at the home. Five service users were out on placements. The inspector was able to meet with the remaining four service users. Service users appeared comfortable and relaxed. Service users informed the inspectors that they were happy at the home and that staff treated them well. GPs, Care Managers and Health Care Professionals were asked to comment on the homes service provision, no responses were received. Staff informed the inspector that they enjoyed working at the home and felt that they had received the training they needed to meet the needs of service users. The inspector was given unrestricted access to all parts of the home and records requested were made available. The inspector would like to thank service users and staff for their time and cooperation with the inspection process. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. What the service does well: Sharpe House provides a homely environment for up to ten adults under 65yrs, who have a learning disability. All service users have their own bedrooms which they can personalise. The home is conveniently situated in the heart of the small town of Wiveliscombe, close to shops and local bus routes. Sharpe House DS0000046271.V338274.R01.S.doc Version 5.2 Page 6 The home has a relaxed atmosphere and service users are supported to choose how and where to spend their day. Service users are supported to develop and maintain independent living skills in line with their agreed plan of care. Care plans are written in an appropriate symbol format for service users. The home’s care planning procedures are good and ensure that the needs and preferences of service users are clearly identified. The home ensures that service users have access to appropriate healthcare professionals. Staff support service users to attend appointments as required or requested. The inspector was able to see evidence that all service users were involved in regular meetings at the home and that their views and ideas were encouraged. The minutes of a recent meeting were displayed in the home for service users in symbol format. The inspector was able to see that service users had been involved in choosing the location for this years summer holiday. Staff follow correct procedures for the management and administration of service users medication. All staff have received appropriate training. The home follows robust staff recruitment procedures which reduce the risk of harm or abuse to service users. The home is adequately staffed and staff spoken with informed the inspector that they enjoyed working at Sharpe House. Staff were observed communicating with service users in a kind and respectful manner. The home takes appropriate steps to ensure the health & safety of persons at the home. What has improved since the last inspection? The home has taken appropriate steps to ensure that service users have access to appropriate healthcare professionals. Care records examined were up to date and had been appropriately signed The home’s procedures for the management and administration of service users medication have improved. As required at the last inspection, appropriate records are now maintained for medicines received into the home. The home has taken steps to ensure that the temperatures of hot water outlets are maintained within acceptable limits. Sharpe House DS0000046271.V338274.R01.S.doc Version 5.2 Page 7 Regular meetings are held for service users and the home now has an effective quality assurance programme which seeks the views of other stakeholders. 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. Sharpe House DS0000046271.V338274.R01.S.doc Version 5.2 Page 8 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 Sharpe House DS0000046271.V338274.R01.S.doc Version 5.2 Page 9 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, 3 & 4 Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. Prospective service users are provided with the information they need to make an informed choice about living at the home. The home has appropriate systems in place to ensure that the needs and preferences of prospective service users are fully assessed. EVIDENCE: The home has produced a Statement of Purpose and Service User Guide which clearly identifies services offered by the home and ‘additional charges’. Additional charges include those for toiletries, hairdressing, transport some activities and chiropody. The home has two cars and service users currently contribute 50 of their DLA mobility component towards the cost of transport. Staff spoken with during the inspection informed the inspector that service users are taken out regularly in the home’s cars. The CSCI have not been advised of any changes to the Statement of Purpose or Service User guide. Sharpe House DS0000046271.V338274.R01.S.doc Version 5.2 Page 10 The home has not any admissions since November 2002. Therefore, Key Standard 2 could not be fully assessed. The inspector was previously informed that a detailed pre-admission assessment would be completed and visits to the home and overnight stays would be encouraged before any decisions were made by the service user or any other interested stakeholders. The home has taken appropriate steps to ensure that staff working at the home have received appropriate training. Records indicated that staff have received recent training in Somerset Total communication, medicines, epilepsy, first aid, moving and handling and health & safety. Sharpe House DS0000046271.V338274.R01.S.doc Version 5.2 Page 11 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, 8, 9 and 10 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The home’s care planning systems are good and are produced in an appropriate format for service users. Service users are given the opportunity to give their views/ideas about life at the home. The home supports service users to take risks as part of their agreed plan of care. EVIDENCE: Three service user care plans were examined in detail at this inspection. All contained up to date information regarding the needs and preferences of the individual. Sharpe House DS0000046271.V338274.R01.S.doc Version 5.2 Page 12 Care plans had been personalised and written in symbol format for the service user. The home’s complaints procedure and service user guide were also available in symbol format. Care plans contained information in relation to health care needs. The inspector was able to see evidence that service users had regular access to appropriate healthcare professionals. The home monitors service users’ weights on a monthly basis and, as appropriate, recording charts are maintained for those service users with epilepsy. Each service user is allocated a key worker and staff spoken with confirmed that this system worked well for service users. One service user spoken with was keen to tell the inspector the role of their key worker. Detailed 3 & 6monthly reviews were available in each care plan examined. There was evidence that the service user and/or their representative had been involved in the review process. Individual environmental risk assessments were in place and had been recently reviewed and dated. Service users are supported to take risks as part of their agreed plan of care. Care plans contained up to date photographs of the individual and missing person forms had been completed. The inspector was able to see evidence that all service users were involved in regular meetings at the home and that their views and ideas were encouraged. The minutes of a recent meeting were displayed in the home for service users in symbol format. The inspector was able to see that service users had been involved in choosing the location for this years summer holiday. At the time of this inspection all records pertaining to service users, were securely stored in accordance with the Data Protection Act 1998. Sharpe House DS0000046271.V338274.R01.S.doc Version 5.2 Page 13 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): 11, 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. The home supports service users to access opportunities within the local community. Service users have access to a range of activities. The home supports service users to maintain links with family and friends. EVIDENCE: Each service user has a planed programme of activities that is agreed and incorporated in to their plan of care. Service users access a local day care provision in Taunton and one service user informed the inspector that they enjoyed attending their workpower placements as they enjoyed learning new skills and getting paid. Sharpe House DS0000046271.V338274.R01.S.doc Version 5.2 Page 14 The home supports service users to access facilities in the local community. Service users access local shops and pubs, some independently and some with staff support. Some service users attend a fitness class at the local school. On the day of the inspection, one service user was catching the bus into Taunton to go swimming, another service user returned from a walk. The minutes of the last service user meeting held on 4th April 07, were seen and the inspector was able to see that service users had been given the opportunity to discuss their preferences for activities. At the time of the inspection, the atmosphere at the home was relaxed. Service users who were able, were observed moving freely around the home. Service users can access their bedrooms at any time and are able to lock their rooms. This was observed during the inspection. As part of the agreed plan of care, one service user was observed cleaning their bedroom. The service user informed the inspector that they liked to clean their bedroom. The home encourages contact with service users families and friends. The Inspector viewed the records kept in relation to the contact with relatives and friends. Some service users frequently go home to their parent’s house for a day or longer periods. One service user informed the inspector that they were looking forward to a visit to see family in Scotland. Meals are prepared at the home and the home makes good use of local produce. Service users are involved in planning the menu and for shopping for local produce. As many service users are out during the day, the main meal is enjoyed at teatime. Staff eat with service users for this meal. Service users spoken with informed the inspector that they enjoyed the food and could choose what they liked. This was observed during lunch time when one service user requested baked beans and hot dog sausages instead of sandwiches. Service users are supported as appropriate, to learn cooking skills. Sharpe House DS0000046271.V338274.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. Service users are supported to meet their personal and healthcare needs. The home’s procedures for the management and administration of service users’ medication are good. EVIDENCE: The needs and preferences of service users are clearly set out in their agreed plan of care. Service users able to express a view, informed the inspector that staff assisted them with some personal care needs in a kind and respectful manner. Staff spoken with during this inspection appeared to have a good knowledge as to the needs and preferences of service users. Service users appeared well attired and staff were heard interacting with individuals’ in a kind and sensitive manner. Sharpe House DS0000046271.V338274.R01.S.doc Version 5.2 Page 16 As previously mentioned in this report, the home ensures that service users have access to appropriate healthcare professionals. Evidence of this was seen in the three care plans examined. Staff support service users to attend appointments as required or requested. The inspector examined the home’s procedures for the management and administration of service users’ medication. The home uses the monitored dosage system (MDS) with pre-printed medication administration records (MAR). Medicines were found to be securely stored with no excess stocks. MAR charts had been appropriately completed and photos of service users were attached. Appropriate records are maintained for medicines received into the home and returned to the pharmacy. The inspector was able to evidence that all staff had received up to date training in the management and administration of medication. Sharpe House DS0000046271.V338274.R01.S.doc Version 5.2 Page 17 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 & 23 Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. The home ensures that service users are given the opportunity to raise concerns. The home takes appropriate steps to reduce the risk of harm or abuse to service users EVIDENCE: The home displays a clear complaints procedure for service users. The complaints procedure has been produced in symbol format. The complaints procedure contains the contact details of the Commission. Service users are encouraged to express their views during regular meetings. Service users who were able to express a view, informed the inspector that they did not have any concerns and that if they did, they would not hesitate in raising them. No complaints have been received by the Commission about the home. The home has policies and procedures in place for staff to reduce the risk of harm or abuse to service users. A selection were examined at this inspection. The home’s policies relating to ‘abuse to staff’, ‘managing aggression’, and physical intervention’ were good and contained clear information for staff. Sharpe House DS0000046271.V338274.R01.S.doc Version 5.2 Page 18 The home’s ‘whistle-blowing’ policy needs updating to include the contact details of appropriate external contacts. The policy also needs to clearly identify how and when staff should make contact with the local vulnerable adults team and the procedures to be followed. A copy of the revised (May 2007) guidance on Somerset’s policy on Safeguarding vulnerable Adults should be available in the home. The home follows robust staff recruitment procedures which include enhanced criminal record checks (CRB) and protection of vulnerable adult checks (POVA). A selection of records relating to service users monies managed by the home, were examined and found to be appropriately completed. Sharpe House DS0000046271.V338274.R01.S.doc Version 5.2 Page 19 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, 25, 26, 27, 28 and 30 Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. Service users live in a comfortable homely environment close to local shops and bus routes. All bedrooms are for single occupancy and service users can personalise their bedrooms. The home takes appropriate steps to reduce the risk of the spread of infection. EVIDENCE: Given the layout of the home, Sharpe House would not be suitable for service users with mobility difficulties and is not registered to accommodate service users with a physical disability. Sharpe House DS0000046271.V338274.R01.S.doc Version 5.2 Page 20 Sharpe House is a large detached property situated in the heart of the small town of Wiveliscombe. Local shops and bus routes are within a short walking distance of the home. All ten service users are accommodated in single bedrooms. Bedrooms are located on the ground and first floor and have the provision of wash hand basins. Service users are able to lock their rooms. Service users spoken with at this inspection informed the inspector that they liked their bedrooms. A selection of bedrooms were seen and the inspector was able to see that service users were encouraged to personalise their private space. Communal areas are located on the ground floor and consist of a dining room/lounge, lounge and large conservatory. Service users were observed utilising both lounge areas during this inspection. Some areas of the home would benefit from redecoration though the home has a plan in place to address this. Currently the conservatory is not being utilised to its’ full potential. The area appears sparse and the flooring needs replacing. On examination of the minutes of a recent service user and staff meeting, the inspector was able to see that this had been discussed and all had been given the opportunity to express ideas and comments on the flooring. The type of floor covering has been agreed and has been ordered. The kitchen is located on the first floor and is domestic in style. Cleaning is carried out by care staff and, as appropriate, service users. At the time of this inspection the kitchen was clean and appeared adequately stocked. Environmental Health examined the homes’ kitchen on 6th February 2007. No concerns were raised. Bathrooms and toilets are domestic in style and appear adequate for the current service user group. Hand washing facilities are appropriately sited to reduce the risk of the spread of infection. The home has a no smoking policy. Service users wishing to smoke are able to use the garden area. The home has suitable sleeping-in accommodation for staff. The home has a good sized garden and some parking. Sharpe House DS0000046271.V338274.R01.S.doc Version 5.2 Page 21 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): 31, 32, 33, 34, 35 & 36 Quality in this outcome area is Adequate This judgement has been made using available evidence including a visit to this service. Service users benefit from a small stable team of staff. Staff training is generally good though the induction programme for newly appointed staff needs improving. The home needs to promote NVQ training for staff. The home follows robust staff recruitment procedures. EVIDENCE: Sharpe House has a small staff team. The home does not use agency staff. All staff are issued with a job description and staff spoken with were clear about their role and responsibilities. Staff are appropriately trained and each staff member has a training and development plan. Recent training has included medication, epilepsy, Somerset Sharpe House DS0000046271.V338274.R01.S.doc Version 5.2 Page 22 total communication, managing challenging behaviour, Learning Disability Awards Framework (LDAF), fire safety, health & safety, first aid and moving & handling. The inspector spoke with two members of staff who informed the inspector that they were registered nurses in their country of origin. They informed the inspector that the home had recently made an unsuccessful attempt to register them for an NVQ qualification. Both expressed their disappointment though were hoping that this would soon be addressed. Pre-inspection information supplied by the home indicated that although no staff have yet achieved an NVQ award, three staff were currently working towards this. The National Minimum Standards recommend that at least 50 of the care team have an NVQ level 2 in care as a minimum. At the time of this inspection nine service users were living at the home. Two care staff were on duty. The inspector was informed that staffing is increased as required to meet the social needs of service users. Nights are currently staffed with two ‘sleep-in’ care staff. Staff spoken with felt that staffing levels were adequate and no concerns were expressed by service users spoken with. Service users commented on the kindness of staff and stated that they ‘will always help you if you need it’. One member of staff has been employed since the last inspection. The inspector was able to examine the recruitment file for this staff member and found that all required information was available. This included an enhanced criminal records check (CRB ) and protection of vulnerable adults check (POVA). On employment, staff undergo a period of induction. Records were examined. Records indicated that staff have only one ‘shadow shift’ before completing the remainder of their two week induction as part of the care team. The home’s induction programme should be reviewed in line with the Skills for Care Common Induction Standards as this ensures that staff receive a thorough induction programme covering a 12 week period. Staff should also follow the Learning Disability Awards Framework (LDAF). The inspector noted that staff supervision sessions have decreased since the last inspection. Records seen did not demonstrate that staff were receiving at least 6 formal supervision sessions a year. It has been recommended that action is taken to address this. Sharpe House DS0000046271.V338274.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): 38, 39, 41, 42 & 43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home does not currently have a registered manager though satisfactory systems are in place. A manager is due to commence in August. The views of service users and staff are sought through regular meetings. The home has an effective quality assurance programme in place. The home takes appropriate steps to ensure the health & safety of persons at the home. EVIDENCE: Sharpe House DS0000046271.V338274.R01.S.doc Version 5.2 Page 24 The registered manager has recently left his post so standard 37 could not be fully assessed. The registered provider has increased his support to the home through regular visits and has kept the Commission informed of changes in the management structure. An acting manager is in post. Following this inspection, the Commission have been informed by the registered provider that an experienced manager has been now been employed and is due to start at the home in August ‘07 The registered provider chairs regular staff and service user meetings. As previously mentioned in this report, minutes are maintained and are displayed for service users in symbol format. Service users who were able to express a view, and staff stated that they felt well informed. In addition to his other visits, the registered provider conducts monthly visits to the home in line with Regulation 26 of the Care Homes Regulations 2001. Detailed reports are submitted to the Commission. The home has developed a quality assurance system which seeks the views of service users and other stakeholders. All records pertaining to service users were seen to be securely stored in accordance with the Data Protection Act 1998. At the time of this inspection, the home is taking appropriate steps to ensure the health & safety of persons at the home. This was ascertained by a tour of the premises, discussion with staff and on examination of the following records; FIRE SAFETY – The home has a fire risk assessment in place. The fire officer visited the home on 15/02/07 and findings of the audit were satisfactory. An automatic door closure has been fitted to the office door as recommended by the fire officer. The home conducts weekly checks on its’ fire alarm system. The last check was done on 25/06/07. Emergency lighting is checked monthly. The last check was carried out on 12/06/07. Systems and fire fighting equipment received its annual service by an external contractor on 19/02/07. Staff have received regular fire safety training and the last fire drill for staff and service users was carried out on 12/03/07. ELECTRICAL SAFETY –The home has an up to date electrical hardwiring certificate dated 09/11/04 and valid for 5 years. Checks on portable appliances were up to date. The last check was carried out on 21/09/06. Sharpe House DS0000046271.V338274.R01.S.doc Version 5.2 Page 25 LEGIONELLA – The home conducts weekly checks on outlets and ensures that water outlets are flushed through as appropriate. This was last carried out on 25/06/07. HOT WATER- The home maintains monthly records of the temperature of the hot water outlets. The records viewed indicated good record keeping with showers and hot water outlets within recommended temperatures. The last check was conducted on 14/06/07. GAS SAFETY – The home’s last annual gas safety check was conducted on 07/02/07. ACCIDENTS – Appropriate records are maintained. Two accidents had been recorded this year. FIRST AID – Training records seen at this inspection indicated that all staff had received up to date training in First Aid. FOOD SAFETY – The Inspectors was informed that staff involved in the preparation of food have an appropriate food hygiene certificate. Staff training records seen by the inspectors confirmed this. The home keeps daily records of fridge and freezer temperatures. No concerns were raised by Environmental Health when they visited the home on 06/02/07. The home has appropriate infection control procedures in place. Detailed safety records (COSHH) are maintained for all cleaning materials in use. The registered providers financial/business plan was not requested for this inspection. The home displays up to date employers liability insurance. Sharpe House DS0000046271.V338274.R01.S.doc Version 5.2 Page 26 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 3 4 3 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 3 26 3 27 3 28 3 29 x 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 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 x 3 2 x 3 3 3 Sharpe House DS0000046271.V338274.R01.S.doc Version 5.2 Page 27 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA23 Good Practice Recommendations The registered person should ensure that the whistleblowing policy is updated to include more detailed information regarding the protocol for the involvement of the adult protection team. The registered person should ensure that at least 50 of the care team achieve a minimum of an NVQ level 2 in care. The registered person should ensure that the staff induction programme meets with the Skills for Care Common Induction Standards and Learning Disability Awards Framework (LDAF). The registered person should ensure that all staff receive formal supervision sessions at least six times a year. The registered person should seek the views of all service users and interested stakeholders as part of the homes quality assurance and quality monitoring systems. 2. 3. YA32 YA35 4. 5. YA36 YA39 Sharpe House DS0000046271.V338274.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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. 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