Inspection on 31/10/06 for Sheringham House

This inspection was carried out on 31st October 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sheringham House 30/08/07

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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 Helen Martin Key Unannounced Inspection 31st October 2006 13:40 Sheringham House DS0000067299.V301295.R02.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.V301295.R02.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.V301295.R02.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.V301295.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: N/A Date of last inspection N/A 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 ensuite toilet facilities; nine out of ten rooms provide ensuite 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. 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.V301295.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place on 31st October 2006 from 13.40 until 18.30. The visit included talking with the manager, support workers and one relative and spending time with the people who live at the home. Some judgements about the quality of life within the home were taken from observation and conversation. Some records were looked at. A tour of the home was undertaken. The home has given the CSCI a completed preinspection questionnaire and this information has been used within this inspection. Postal surveys from residents, their relatives and health and social care professionals could not be included within this inspection as none had been received at the time of writing this report. Sheringham House currently has eight residents with two vacancies. What the service does well: Before they move in, residents are assessed and are able to visit, so they know if the home will suit them. They are told how much it will cost. There is an open and friendly atmosphere in the home, which is well run around the interests of people who live there. Staff listen to what residents want and what they are unhappy about and take action. People enjoy living in a clean, comfortable and homely house. Residents are given the help they need in private and staff are polite to them. They are able to make up their own minds about what they do. Residents can be themselves and have lots of chances to socialise with other people, enjoy their hobbies and learn more skills. Residents are able to see their family and friends whenever they want to. There are enough trained staff in the home to help residents when they need it. Staff understand what residents need and are supervised by the manager. Staff don’t tell people who are not meant to know, anything about residents. Some things that a relative of residents said to the inspector when they visited the home were that their family member had blossomed since living at the home, they have become a person in their own right, they are respected, their health care needs are met properly, they are taken out and do things and they enjoy the meals. A visitor said that staff attitude was good; they were polite and nice, they were able to look around the home before their relative moved in, they could visit whenever they wanted to, they had no complaints and were very happy with the care that the home provided. Sheringham House DS0000067299.V301295.R02.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. Sheringham House DS0000067299.V301295.R02.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.V301295.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who are considering moving into this home are assessed as to whether their needs can be met. They are given information about their individual fees although no other information regarding their terms and conditions of accommodation. EVIDENCE: A statement of purpose and service users guide is provided, which contains information about the home. This was assessed as appropriate in May 2006 when the home was first registered. The manager indicated that no changes have been made since this time. It was unclear at the time of this visit whether all residents and their representatives had received this information before they moved into the home. Residents benefit from assessments before they move into the home, to ensure that their needs can be met. Local authority documentation was seen. It was said that no residents are currently privately funded. In addition to the local authority both the home and the organisation undertake assessments of residents prior to their admission. Sheringham House DS0000067299.V301295.R02.S.doc Version 5.2 Page 9 The manager demonstrated an understanding of the range of needs that the home could and could not meet. Current residents’ needs vary. Residents’ challenging behaviour was discussed. The manager described a range of measures that are in place including close supervision of two residents, input from families and care managers, specialist support from a learning disability nurse and psychologist, staff training and guidelines. A programme is underway, which aims to improve communication with residents. Staff guidelines are reviewed on an ongoing basis. The manager stated that the effect of challenging behaviour on the whole of the resident group was assessed on an ongoing basis. Prospective residents and their representatives are able to look around the home. Before they moved in, one resident, their relative and advocate were able to visit. The contract between residents and the home only contains information about the fees. Sheringham House DS0000067299.V301295.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to make their own choices and decisions about their lives. Information about them is kept confidential. Their changing needs could be better reflected in care plans. EVIDENCE: Documentation reflects residents’ changing needs and gives staff some guidance about action to be taken to promote their health and welfare. Information contains a range of issues. Reviews are ongoing. Although information seen was up to date and staff guidelines detailed, the home does not produce their own cohesive plan of care, which would provide clear objectives and staff guidance about how to achieve all the goals identified. Not all information is kept within individual care planning files. The manager said that they continued to be in the process of transferring relevant information from residents’ care plans in their previous homes. There are some blank entries in daily notes where residents have been visiting their families. There is no evidence to suggest that residents are involved within their care planning. Sheringham House DS0000067299.V301295.R02.S.doc Version 5.2 Page 11 Residents are supported to take risks as part of maximising their independence. Risk assessments and staff guidelines are recorded. All information seen was reviewed and up to date. Discussion around this issue indicated that people living in the home are given the freedom to make decisions about their lives considering risk management and group living. They are provided with assistance to support their individual choices. Regular residents’ meetings are held about decisions such as meals, likes, dislikes, policies and activities. Residents’ challenging behaviour has been mentioned previously within this report. Residents’ confidentiality is maintained and their privacy respected, in that personal records are maintained and stored in such a way as to be available solely to appropriate and authorised people. Sheringham House DS0000067299.V301295.R02.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 at least once during a 12 month period. 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. Residents enjoy individual lifestyles and are supported to develop their life skills. They have the opportunity to experience a variety of social, educational and recreational activities. Residents would benefit from the full cost of a holiday included in the contract price. EVIDENCE: Residents benefit from opportunities for personal, emotional and social development and are supported towards improving their living skills, tailored to their abilities. Residents are treated as individuals and have different interests, aspirations and abilities. A relative of a resident confirmed this. Personal development is enabled for through attendance at college, day centres, leisure activities and relationships with friends and family. Residents are part of the local community. Transport is provided by the home. Staff at the home support their attendance at day centres and college and also Sheringham House DS0000067299.V301295.R02.S.doc Version 5.2 Page 13 provide activities from the home. A range of opportunities are available to residents including swimming, ice skating, walking, breakfast in a local restaurant, gardening, art and craft, drama, aromatherapy and visits to parks. A music class is planned. There is a sensory building in the grounds. A local college is running horticulture and cookery classes within the home for residents. One resident attends college to improve their numeracy and literacy skills. Residents are currently undertaking a programme to improve their communication skills. Residents are able to see their family and friends as often as they wish. Individuals can visit the home at any reasonable time and this was confirmed by one relative at the time of the visit. One resident stays with their family on a regular basis. Residents spend time in the home relaxing or undertaking activities that interest them. They also receive guidance with the development of skills within the home with the support of staff. Residents are encouraged with laundry and household tasks. They enjoy privacy in their rooms and staff respect this. Staff talk to residents in a friendly and polite way. The manager stated that, as the home had only been open since May 2006, no holidays had been provided for residents this year. It was stated that these are being planned for next year. Residents are supported to choose their meals and menus are recorded. Meals are in accordance with agreed menus, known choices and nutritional needs or preferences. The manager said that one resident is supported with a special diet and information is available to staff. One visitor said that their relative enjoyed the food at the home. Sheringham House DS0000067299.V301295.R02.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 at least once during a 12 month period. 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. Residents benefit from personal support which meets their individual needs. Their privacy and dignity is respected. Residents would be better protected by a review of the policy in the home for the administration of medication. EVIDENCE: Residents are given the personal support they need to maximise their independence, while respecting their dignity and privacy. They are able to exercise choice regarding this. Staff demonstrated a good understanding of the preferred routines and varying requirements of each individual and detailed guidelines are available. A programme is underway, which aims to improve communication with residents, using Makaton, signing and pictures. Residents have access to social and health care professionals, such as GP, learning disability nurse, epilepsy nurse and psychologist. Input from a speech and language therapist is planned. They are supported with any specialist hospital appointments and/or interventions. The manager and staff demonstrated a good understanding of the needs of residents. Staff guidelines are available for residents with specialist needs. Residents’ challenging Sheringham House DS0000067299.V301295.R02.S.doc Version 5.2 Page 15 behaviour has been mentioned previously within this report. Individuals’ weight is monitored and food and drink consumed is recorded. One visitor said that the health care needs of their relative are handled appropriately by the home. A procedure is in place for the administration of medication by the home, which aims to protect residents. Storage is secure and room temperatures are monitored. Administration records are completed appropriately; the manager stated that amendments to records had eliminated previous errors. Guidelines for the administration of ‘when required’ medication are provided. All medication is prescribed on an individual basis and the home does not use ‘homely remedies’. The manager said that only trained staff administer medication. The manager is in the process of updating the medication policy and will include procedures specific to the home. Sheringham House DS0000067299.V301295.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ views and concerns are listened to and receive appropriate consideration. Residents could be better protected from potential abuse by a review of the systems for the containment of challenging behaviour and individuals personal finance. EVIDENCE: Residents are at ease with staff who listen to their views and concerns. A regular meeting is held to discuss these. Residents receive continuity of care by having individual key workers. The home provides a written complaints procedure. One relative of a resident said that they had no complaints about the home and were very happy with the care. The manager confirmed that no complaints had been received, but that appropriate records would be kept, should this be the case. Procedures are in place, which aim to protect residents from potential abuse. Staff have access to adult protection, whistleblowing, challenging behaviour and physical intervention policies. Residents’ challenging behaviour has been mentioned previously within this report. It was stated that families and care managers are informed in detail of all incidents. Nine notifications of incidents have been received by the CSCI. The manager demonstrated a good understanding of adult protection procedures. Since the last inspection, one adult protection investigation has been undertaken, which has since been closed. The manager stated that two Sheringham House DS0000067299.V301295.R02.S.doc Version 5.2 Page 17 residents are provided with close supervision and staff guidelines and risk assessments have been updated accordingly. The manager stated that the effect of challenging behaviour on the whole of the resident group was assessed on an ongoing basis. The manager and staff stated that currently one resident does not pose a high risk to the rest of the resident group. The home is currently undertaking a programme with this individual to improve communication. The home has a system in place, which aims to protect the financial interests of residents and holds small amounts of cash on their behalf. This is kept securely. All money is stored individually and transaction records are maintained. Cash checked tallied with accounts seen. Receipts are kept for purchases made on residents’ behalf. The manager said that no one within the organisation was an appointee for any resident. Discussion took place regarding the method of accessing some residents’ bank accounts. It was agreed that current procedures did not adequately protect the individuals concerned. The manager undertook to address this as soon as possible. Residents’ personal property and valuables are recorded. Not all records are signed by staff and the resident and/or their representative. Sheringham House DS0000067299.V301295.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a clean, comfortable and homely environment. EVIDENCE: The building fits in with the local community and has a style and atmosphere that meets individuals’ needs. Residents benefit from living in clean and comfortable accommodation. They have access to a large garden and sensory building. The home is well maintained and decorated. Good recreational, dining, toilet, bathing and individual accommodation are available to residents. The home provides a lounge and dining area. All residents have their own rooms, which are big enough to store their possessions. All contain ensuite toilet facilities; nine out of ten rooms provide ensuite bathing or shower facilities. The accommodation is arranged over two floors. Bedrooms are comfortable, furnished and decorated according to individual taste and reflect the interests of the occupant. Sheringham House DS0000067299.V301295.R02.S.doc Version 5.2 Page 19 Although some wheelchairs are provided, the manager indicated that no other specialist disability equipment is needed. There are no passenger or stair lifts within the home and it was stated that residents provided with accommodation on the first floor have no mobility problems. It was stated that a rehabilitation agency was shortly to undertake an assessment. There is a staff call system throughout the home. The premises are clean and hygienic. There is a laundry room used by residents with support from staff; appropriate procedures are in place for infection control. Sheringham House DS0000067299.V301295.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 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. Residents benefit from a sufficient number of appropriately trained and supervised staff who have a good understanding of their needs. They would benefit from the opportunity for staff to gain additional qualifications. EVIDENCE: People living in the home benefit from the support of enthusiastic and caring staff, who demonstrate a good understanding of their needs. Residents benefit from good support and interaction. A relative of one individual confirmed this. The home aims to meet the needs of residents by providing appropriate staff training. The manager said that an ongoing programme was provided. A support worker said that they had undertaken training in challenging behaviour, physical intervention, fire, medication and health and safety. Staff records seen also detailed training as including induction, first aid, food hygiene, the protection of vulnerable adults, infection control, autism, epilepsy, medication, manual handling, dementia, learning disability and mental health, sexual health and care planning. Currently four of the seventeen support workers have obtained an NVQ qualification. The manager said that they aimed Sheringham House DS0000067299.V301295.R02.S.doc Version 5.2 Page 21 for additional courses to commence shortly. One training provider had provided documentation specific to the home regarding physical intervention. At the time of the site visit, there were sufficient numbers of staff on duty to support people within the home. Staffing numbers include close supervision for two residents. The manager said that currently there are four staff vacancies that are covered by overtime or agency workers. There are always core staff present and the home is in the process of recruitment. There is a stable staff team. A recruitment procedure is in place that aims to protect residents and appoint staff suitable to meet their needs. Staff files seen contained evidence of appropriate recruitment procedures for the protection of residents. Documentation included POVA (protection of vulnerable adults) First and enhanced criminal records bureau checks. The manager confirmed that most staff are employed after the receipt of a full criminal records bureau check. It was stated that those staff employed before this was received were supervised appropriately. The manager said that staff supervision was undertaken on an ongoing and regular basis to ensure that their work is monitored and training and development needs are identified. It was stated that regular staff meetings held monthly and recorded. Sheringham House DS0000067299.V301295.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is run effectively and in the best interests of residents, although they would benefit from the qualification of the manager. Residents could be better protected by improvements to record keeping and a review of policies and procedures. EVIDENCE: The manager has relevant experience of service provision for older people and for people with learning disabilities. They have previous management experience. The manager has obtained the Registered Managers’ Award and is in the process of undertaking an NVQ qualification at level 4. There is an open and inclusive atmosphere in the home. Regular meetings for residents and staff are held. Sheringham House DS0000067299.V301295.R02.S.doc Version 5.2 Page 23 The quality assurance system for the home was discussed. The manager explained that they would send questionnaires out shortly, including to residents’ relatives and relevant health and social care professionals. A regular residents’ meeting is held to discuss individuals’ views. The home has comprehensive recorded policies and procedures that are available for staff, although these are in need of updating. The manager explained that all policies and procedures were currently in the process of review. In order to evidence consistency of care for residents, a number of records have been looked at as part of the inspection process. These have been mentioned within this report where appropriate. Accidents and incidents are recorded appropriately and the relevant people and agencies are notified. Information provided within the home’s pre-inspection questionnaire and some records seen indicated the regular testing and maintenance of systems and equipment within the home. Fridge, freezer and hot food temperatures, the house vehicle, the fire alarm and emergency lights are monitored and recorded on a regular basis. Cleaning chemicals are locked away. Residents’ challenging behaviour has been mentioned previously within this report. Sheringham House DS0000067299.V301295.R02.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 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 4 28 4 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 2 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 3 3 2 2 3 X Sheringham House DS0000067299.V301295.R02.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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 YA6 YA41 Regulation 15 & 17 (1)(a) Requirement The registered person shall prepare a written plan as to how the service users needs in respect of his health and welfare are to be met and shall keep the service users plan under review. In that, although up to date information is available, the home must produce a cohesive plan of care. This must provide objectives and clear staff guidance about how to achieve all the goals identified. 2 YA23 13(6) The registered person shall make 01/12/06 arrangements…to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. In that, a review must be undertaken to ensure that the home can contain the challenging behaviour of residents. Residents must not be harmed or suffer abuse or be placed at the risk of harm and abuse. Timescale for action 01/12/06 Sheringham House DS0000067299.V301295.R02.S.doc Version 5.2 Page 26 A review must be undertaken regarding the method of accessing residents’ personal bank accounts. Procedures must be fully accountable and protect residents from the risk of abuse. 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 It is recommended that a review should take place to confirm that all residents and their representatives have received copies of the home’s statement of purpose and service users’ guide. It is strongly recommended that the contract between residents and the home should be reviewed to include all items listed within Standard 5. It is recommended that, with regard to care planning: 1. Residents should be involved with their care plans. 2. Days that residents spend away from the home staying with their families should be recorded in daily notes and not left blank. 4 YA14 The manager stated that, as the home had only been open since May 2006, no holidays had been provided for residents this year. It was stated that these are being planned for next year. It is recommended that the manager fulfil their stated intention to complete planning for the provision of holidays for residents. It is strongly recommended that, with regard to policies and procedures: 1. The manager should complete their stated intention to update all policies and procedures as soon as possible. Sheringham House DS0000067299.V301295.R02.S.doc Version 5.2 Page 27 2 YA5 3 YA6 5 YA20 YA40 2. The medication policy should include procedures specific to the home. 6 YA23 It is recommended that staff and the resident and/or their representative should sign records of personal property and valuables. 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 their NVQ level 4 qualification as soon as possible. 7 YA32 8 YA37 Sheringham House DS0000067299.V301295.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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