Inspection on 30/08/07 for Sheringham House

This inspection was carried out on 30th August 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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sheringham House 31/10/06

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

CARE HOME ADULTS 18-65 Sheringham House 54 Old Road East Gravesend Kent DA12 1NR Lead Inspector Jenny McGookin Key Unannounced Inspection 30th August 2007 10:00 Sheringham House DS0000067299.V346034.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 Sheringham House DS0000067299.V346034.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. Sheringham House DS0000067299.V346034.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sheringham House Address 54 Old Road East Gravesend Kent DA12 1NR 01474 329807 01474 328285 Sheringham.house@achuk.com www.achuk.com Aitch Care Homes (London) Limited Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (If applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Ian John Pitman Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Sheringham House DS0000067299.V346034.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st October 2006 Brief Description of the Service: Sheringham House provides a service for up to ten adults with a learning disability. The home has an organisational structure, which includes a manager and support workers, operating a roster, which gives 24-hour cover. There are no designated staff for catering or domestic duties. All residents are accommodated in single rooms. All contain en-suite toilet facilities; nine out of ten rooms provide en-suite bathing or shower facilities. The accommodation is arranged over two floors. There is no passenger lift. Good communal space is provided with a large garden and additional sensory building. The care providers are AITCH Care Homes (London) Limited, who have been operating since November 2001. The home is located in Gravesend within easy reach of the usual town facilities and public transport. The current core fee for the home is £1,354.77 per week. Any additional charges are agreed individually with local authorities for those residents who require more support than that allowed for in the core fee. Full information about the fees payable, the service provided, the home’s Statement of Purpose and the latest inspection report by the CSCI are available from the manager. Sheringham House DS0000067299.V346034.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection site visit, which was intended to review findings on the last inspection (October 2006) in respect of the day-to day running of the home; and to check compliance with matters raised for attention on that occasion. The inspection process took nine and a quarter hours, and involved meeting with the deputy manager, assistant manager and a support worker. Only two of the service users were able or inclined to interact meaningfully and remained so throughout the day. The inspection involved an assessment of the premises and a range of records. Two service user’s files were selected for care tracking. What the service does well: What has improved since the last inspection? In this home’s opening year it became clear that some aspects of its organisation were not robust enough, and the home needed to learn from lapses. There are now tighter checks and balances in place; and record keeping is more systematic. Sheringham House DS0000067299.V346034.R01.S.doc Version 5.2 Page 6 The development of person-centred care plans and key working are creating consistently positive outcomes for people using the services. There is evidence of service users exercising choices and controls over their daily lives, and being supported to develop skills. The service is benefiting from the positive and proactive approach to comments and suggestions from staff, service users and their representatives. The home is viewed positively by 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. Sheringham House DS0000067299.V346034.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 Sheringham House DS0000067299.V346034.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 1, 2, 3, 4 Prospective service users and their representatives have most of the information needed to decide whether this home will meet their needs. Prospective service users have their needs properly assessed as part of the admission process. EVIDENCE: This home has a Statement of Purpose and Service User Guide, each of which usefully describes the facilities, services and principles of care. Some matters have been raised for attention or consideration to further improve each document. These have been reported back to the home separately. No other languages are currently warranted but the Service User Guide is available as selected extracts in simplified text and is picture-assisted to help the service users’ understanding. An admission checklist is recommended to evidence the issue of these documents so that anyone authorised to inspect the records can be assured that people have all the information available to make informed choices before they move in. This matter was raised for attention by the last inspection and will apply to future admissions. Sheringham House DS0000067299.V346034.R01.S.doc Version 5.2 Page 9 The decision to apply to this home was in each case made by third parties (such as local authorities, in consultation with families) and takes the service users’ responses into account. None of the current service users is self-funding, so each placement is governed by the terms and conditions of the relevant funding authority. This is outside the scope of this inspection, but key terms have been extracted and presented in a more accessible format in the Service User Guide to assist their understanding. The last inspection recommended that the home’s own contract be amended to ensure to fully complies withal the elements of the National Minimum Standards but a copy was not submitted to the Commission in time for assessment. The home carries out its own preadmission assessments and will not, as a matter of policy, take emergency admissions without doing so. Records confirm that it also properly takes assessments from funding authorities into account. Prospective residents or their representative are invited to visit the home, before moving in, and each prospective service user is offered a trial stay of three months before their admission is confirmed. There was good anecdotal information on the way prospective residents were observed during this transition period, though records could be improved. See section on “Environment” for a description of equipment and adaptations, and section on “Health and Personal Care” for a description of services provided. Sheringham House DS0000067299.V346034.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 6, 7, 8, 9, 10 Service users benefit by being involved in decisions about their lives, as far as they are able, and are supported to play an active role in planning the care and support they receive. EVIDENCE: The format of the home’s Person-Centred Plans should enable all aspects of the service users’ health, personal and social care needs to be addressed. The headings are written in the first person (my friends, my family, things I like, dislike etc) to properly keep the service user’s perspective central, though what follows in each case is written in the third person because their perspective has to be largely interpreted to provide staff instruction. Some staff instruction is too generalised and would have universal application. It would not of itself single out one service user’s needs from another. Sheringham House DS0000067299.V346034.R01.S.doc Version 5.2 Page 11 However, these are followed through in daily reports, which require staff to address more specific goals. And they are usefully underpinned by a range of risk assessments (generic and specific), covering the individual, their activities and their environments – on and off site. Service users benefit by the continuity of care offered by the home’s key worker system. The home relies on local authority Care Managers to lead formal reviews of care plans and the Care Managers’ reports properly identify who participates in each case. The home’s manager produces reports for these reviews, with input from each service user’s key workers. There was good evidence of guidelines for managing behaviours and of all these tools being kept under review to ensure their currency. Service users were observed being supported to make choices in their daily living routines during the site visit, as far as they were able. The home’s arrangements for keeping confidential information secure against unauthorized access was judged generally satisfactory. Cabinets are lockable and computerised records are password protected. There is a dedicated office, overlooking the entrance, which is judged a useful safeguard against unauthorised access or egress. Sheringham House DS0000067299.V346034.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 11, 12, 13, 14, 15, 16, 17 Service users benefit by being supported to make choices about their life style, and to develop their life skills. Social and recreational activities meet individual’s assessed needs and interpreted expectations. EVIDENCE: Abilities, activities and personal preferences are established as part of the preadmission assessment process and confirmed by care plans and day-to-day consultation or interpretation (where the service users do not have verbal skills) thereon. An organisation called “Magic Moments” visits to provide music sessions (involving a choice of percussion instruments) and arts and crafts sessions. Sheringham House DS0000067299.V346034.R01.S.doc Version 5.2 Page 13 There are also aromatherapy sessions and a range of sensory room facilities in a summer house on site. During the site visit one service user was observed having a story read to him. One member of staff explained, “the main thing is the tone of voice. Some words have meaning. The narrative can be quite light and pleasant”. The service users also make use of the garden and have annual holidays, though in one case this has been translated into short day trips. None of the service users attend day centres but one service user goes to college and has been awarded certificates of achievement (cookery, film making, trips, handwriting practice). One person also comes in to support the service users with cookery sessions and some have communication sessions. Service users are supported to carry out some household tasks such as loading or unloading washing from the washing machine or dryer, or in the preparation of meals. The home also has the use of a people carrier and car to access community facilities to good effect. The service users go shopping, swimming, ice skating, and bowling. They also go to the cinema, go out for snacks and visit parks i.e. local mainstream community activities not confined to or identifiable with disabilities. In each case the home maintains a programme of planned activities and records of activities actually undertaken. All the staff use a mixture of Makaton, signing and pictures to communicate with the service users. They have had some training in autism, and behaviour management training. There are open visiting arrangements and one service user regularly visits a relative living close by. There are four phones on site. The service users can all use these phones at no charge. Three have their own mobile phones – and the costs of calls are borne by their families. Dietary needs and preferences are established as part of the preadmission assessment process, and confirmed by day-to-day observations and adjustments. The dining area is a light spacious area, which provides a congenial setting for meals, but there are two separate sittings because of the need to manage challenging behaviour. Service users can choose to eat elsewhere. Sheringham House DS0000067299.V346034.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 18, 19, 20 The health and personal care that people receive is based on their individual needs. Service users benefit by the principles of respect, dignity and privacy being put into practice. EVIDENCE: The preadmission and care planning processes assess the extent to which each service user can manage their own personal care, and their choice and control is actively promoted by staff. Daily records are maintained. All the bedrooms are single occupancy. Although most bedroom doors have double-acting locks to guarantee their availability and privacy, they are not in practice used. Observed practice was judged appropriately familiar and respectful, and occasional outbursts were managed effectively. Sheringham House DS0000067299.V346034.R01.S.doc Version 5.2 Page 15 There are enough toilet and personal care facilities (baths, showers, wash hand basins) – and these have been maintained to a high standard. Staff are available on a 24 hour basis to assist service users. There was good anecdotal information about how service users’ incontinence had been successfully managed. The care planning process routinely addresses a range of standard healthcare needs and the home also accesses care managers, learning disability and epilepsy nurses as well as specialists (e.g. psychologists, and in behaviour management interventions) as appropriate. The home uses the monitored dosage system (MDS) from a local chemist, which also carries out periodic inspections. There were something like eleven medication administration errors during the home’s first year of operation. In the event no harm was done but these have been addressed by a review and tighter stock checks and record keeping. An inspection of Medication Administration Record (MAR) sheets showed no apparent anomalies or gaps. Some other matters are raised for attention. See schedule of recommended action. The home keeps its medication in lockable wall-mounted facilities, and monitors the temperatures within. Sheringham House DS0000067299.V346034.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 22, 23 Service users benefit by being supported to express their concerns, and there is a complaints procedure in place. Service users are protected from abuse, and have their rights protected. EVIDENCE: The home has a complaints procedure, which usefully details its guiding principles, and describes the process and timeframes for each stage. A pictorial copy is issued to each service user and there are versions in the home’s Statement of Purpose and Service User Guide. However, the absence of registered complaints is not judged a realistic reflection of communal living, particularly where outbursts are commonplace. The challenge for this home will, therefore, be to interpret expressions of dissatisfaction into recordable events, so that anyone authorised to inspect the records can properly judge compliance with this standard. It is accepted that staff have been given training on interpreting behaviours, with more in prospect. It is also accepted that a recent quality assurance initiative has raised some issues which the manager has undertaken to follow up. The Statement of Purpose commits the home to accessing advocacy services and there was good anecdotal evidence of input by two MENCAP advocates. Sheringham House DS0000067299.V346034.R01.S.doc Version 5.2 Page 17 Staff have access to a range of relevant adult protection policies and have to sign as evidence of their compliance with their provisions: challenging behaviour; complaints; whistle-blowing; adult protection and physical intervention. This list is not exhaustive. Since the last inspection, however, there was one incident where a significant sum of money went missing without detection for several days. Once the discovery was made, the home’s response was appropriate and properly notified to the relevant authorities. And as a direct result, the loss was reimbursed, and arrangements and checks were tightened. In discussions with staff, they have invariably confirmed their commitment to challenge and report any instances of abuse, should it occur. The rapport between staff and the current service user appeared appropriately familiar and respectful. Sheringham House DS0000067299.V346034.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 24, 25, 26, 27, 28, 29, 30 Service users benefit by the provision of a safe, well-maintained and comfortable environment. The physical design and layout of the home encourages freedom of movement and independence. EVIDENCE: The layout of this home is generally suitable for its registered purpose. All areas of the home were inspected and found to be homely and comfortable. And the level of cleanliness is judged exemplary. The furniture tends to be domestic in style and there were homely touches throughout. The front garden is not accessible by service users, because of the dangers posed by the busy road to its front. But there is a large square garden, enclosed on all sides at the rear, which has been largely put to lawn. This area Sheringham House DS0000067299.V346034.R01.S.doc Version 5.2 Page 19 would benefit by the introduction of discrete focal points and areas to walk or sit in. The setting up of a sensory garden could make this facility even more attractive. A summer house has been set up as a sensory room, to good effect. The home has a “No Smoking” policy. The communal areas are all on the ground floor. There is a spacious formal lounge at the front of the home, and a smaller room furnished with a table and chairs for formal meetings or private moments. There is a good range of chairs and bean bags to suite different needs and preferences. One service user uses comfy-wheelchairs. There are no passenger or stair lifts within the home. first floor have no mobility problems. Service users on the The dining room is also at the front of the home and is linked at it far end by a large hatch to the kitchen. All the dining room are uniform in style – this has not caused any discomfort. The kitchen is light, airy, clean and well maintained. There are WC facilities on both floors, and a choice of bath and shower facilities - all of which are reasonably accessible to bedrooms and communal areas; and these are all well maintained. All the bedrooms are spacious and single occupancy. All the bedrooms were inspected and found to be well maintained. All contain en-suite toilet facilities; nine out of ten rooms provide en-suite bathing or shower facilities. In terms of their furniture and fittings, they were generally compliant with the provisions of the National Minimum Standards, and every bedroom also has a TV point. Only a few matters were raised for attention. Sheringham House DS0000067299.V346034.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 31, 32, 33, 34, 35, 36 Service users benefit by staff who are trained, skilled and in sufficient numbers to support them, in line with their terms and conditions, and who support the smooth running of the service. EVIDENCE: The waking / working day has been interpreted as 7.30am till 10.30pm, and the staffing rotas submitted for inspection for a four week period (23 July to 19 August 2007) indicates that visitors should expect to find between four and, more usually, six support staff on duty as well as a person in charge (e.g. the manager). This arrangement was in fact confirmed by this unannounced site visit. At night there are invariably two waking staff on duty, and there are oncall arrangements at all times. There are, however, no dedicated ancillary staff (e.g. cooks or cleaners). These tasks are covered by the staff responsible for direct care. Staff are to be commended for the standard of maintenance and catering found, and it is accepted that the current residents are supported to carry out some light Sheringham House DS0000067299.V346034.R01.S.doc Version 5.2 Page 21 domestic chores as part of this arrangement. But it is not ideal, particularly when three service users are said to require 2:1 staff support. It is difficult to see what scope that offers the other service users for direct support. The manager is detailing his own on-site shifts on staffing rotas, as required; and shift handovers are used to plan the deployment of staff. Flexibility and team working have been identified as key strengths of this team. An examination of personnel files confirmed a sound level of compliance with the National Minimum Standards in respect of recruitment, induction and training. With one exception, all the service users are white British males and in most cases they have very limited verbal skills. The staff team shows more diversity – both genders are represented, and the cultural range includes African, Polish, Irish and British. Particular emphasis is placed on interpreting behaviours, using objects and pictures of reference, Makaton, key words and tones of voices to communicate with the service users. Staff confirmed having had a range of training opportunities, such as food safety, fire safety, medication, health and safety, manual handling, First Aid, autism, intervention and challenging behaviour. See also section on “Lifestyle” for details on specialist input to meet the service users’ special needs. Currently 25 of the staff team are said to have NVQ accreditation with another 25 in close prospect. All staff are issued with copies of the General Social Council Code of Practice, to help ensure compliance with best practice standards. Each member of staff is subject to the terms (including frequency) and conditions of a supervision contract. Staff confirmed that they had formal supervision from their line manager, which in some cases exceeds the frequency prescribed by the National Minimum Standards. And these are underpinned by regular staff group meetings. The registered manager was said to be accessible and supportive. Sheringham House DS0000067299.V346034.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 37, 38, 39, 40, 41, 42, 43 The manager is qualified and competent, and service users benefit by the ethos of the home, which is based on openness and respect. Service users benefit by the quality assurance and business planning systems in place. EVIDENCE: The registered manager has a wide range of relevant qualifications including the Registered Managers Award, and is currently still working towards obtaining NVQ Level 4 accreditation. He also has in excess of 12 years experience working in the field of learning disabilities, and the range of syndromes and disorders (including the autism spectrum) that implies – as well as mental health and mobility difficulties. Sheringham House DS0000067299.V346034.R01.S.doc Version 5.2 Page 23 This is a home, which has already been able to demonstrate good progress with its first admissions. They are clearly benefiting from access to a range of fulfilling activities as well as to mainstream community resources not immediately identifiable with or confined to their special needs. The home has instigated a procedure for Quality Assurance, which includes questionnaires for use with service users, staff and relatives. Initial feedback comments were judged encouraging, and this is underpinned by regular group meetings with service users, their representatives, and staff. The registered manager has ensured that the key policies and procedures prescribed by the CSCI are in place and these are currently undergoing review to ensure compliance with best practice standards. The home has its own staff handbook as well as that issued by the General Social Care Council model. And it also has a copy of the local multi-agency adult protection protocols to ensure a timely and co-ordinated response to any incidents that might arise. Property maintenance records were judged generally in good order and maintained in the best interests of the service users. The home has the required public liability insurance cover. The home’s response to one lapse in its accountability is referred to earlier in this report. Petty cash accounts and financial records have been tightened and are now judged more fully accountable, subject to regular checks and properly supported by receipts. The home has a detailed business plan for the current year, which properly summarises a range of operational considerations – capital and on-costs - as well as performance against the framework of the National Minimum Standards as interpreted by the inspection process. Reports from independent auditors and the company’s own Directors were available for the financial year 2006/7, both of which indicate a sound level of accountability and probity and will, by implication, be subject to annual review thereon. Less clear, however, was the proprietors’ level of compliance with their regulatory duty to carry out documented unannounced inspection visits at least once a month. There were three months not accounted for. Breach of this regulatory duty constitutes an offence. Sheringham House DS0000067299.V346034.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 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 4 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 3 36 3 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 2 X 2 3 3 3 3 3 3 Sheringham House DS0000067299.V346034.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 YA39 Regulation 26 Requirement The proprietors need to evidence a more assured level of compliance with their regulatory duty to carry out documented unannounced inspection visits at least once a month. Breach of this regulatory duty constitutes an offence. Timescale for action 30/09/07 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 2 Refer to Standard YA5 YA20 Good Practice Recommendations It is strongly recommended that the home’s own contract (i.e. for self funders) be reviewed to include all items listed within Standard 5. Medication. The following recommendations are made: • Photographs should be dated as evidence of their currency • Information on individual service users’ medication (purpose, side effects etc) should be stored with MAR charts so as to be readily available • MAR charts should be better secured against loss or disarray DS0000067299.V346034.R01.S.doc Version 5.2 Page 26 Sheringham House • 3 4 YA20 YA24 The home should obtain a copy of The Royal Pharmaceutical Society Guidance, for reference. And should check its own policy for compliance with its provisions. It is strongly recommended the manager should complete is stated intention to update all policies and procedures as soon as possible. Building. The following matters are raised for attention / consideration: • Kitchen windows should be fly proofed with screens when opened or there should be an insectocutor • Recommend sample 1st items made more readily available to kitchen staff for use in emergencies. • Recommend one WC is dedicated for kitchen staff only • Non provision of furniture / fittings listed by the National Minimum Standard for bedrooms needs to be justified with documented risk assessments / consultation It is strongly recommended that a review should be undertaken to ensure that 50 of the staff team achieve an NVQ qualification as soon as possible. It is recommended that the manager complete his NVQ level 4 qualification as soon as possible. 5 6 YA32 YA37 Sheringham House DS0000067299.V346034.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Text phone: 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 Sheringham House DS0000067299.V346034.R01.S.doc Version 5.2 Page 28 - 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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