Inspection on 29/08/07 for Somerset House

This inspection was carried out on 29th 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 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

Somerset House 14/05/09

Somerset House 17/11/06

Somerset House 03/01/06

Somerset House 30/06/05

Somerset House 21/12/04

Somerset House 03/08/04

Somerset House 26/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Somerset House 157 High Street Yatton North Somerset BS49 4DB Lead Inspector Patricia Hellier Key Unannounced Inspection 29th August 2007 09:30 X10015.doc Version 1.40 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 Somerset House DS0000008057.V344473.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Somerset House DS0000008057.V344473.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Somerset House Address 157 High Street Yatton North Somerset BS49 4DB 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) 01934 832114 NONE Mrs Wendy Rita Hiles Mrs Julie Denise Jones Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Somerset House DS0000008057.V344473.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 26 persons aged 65 years and over requiring personal care. 17th November 2006 Date of last inspection Brief Description of the Service: Somerset House provides personal care for up to 26 people over 65 years of age. Somerset House is a pleasant period property situated off the main road through Yatton, with walled gardens that are well kept. The property has been extensively modified and extended. A majority of rooms are situated on the ground floor. Rooms on the first floor are accessed by a stair lift. The premises have a small satellite home, for up to 4 people, suitable for residents who wish to use the support offered by the home, but desire a more private form of accommodation. The provider makes information available through a brochure and information pack. The information pack contains the Statement of Purpose and Service User guide and all relevant information about the home. CSCI reports are displayed in the entrance to the home and available for all to read. The fees range between £356 and £375 a week with additional charges being made for hairdressing, chiropody, newspapers, and toiletries. This information was provided in August 2007. Somerset House DS0000008057.V344473.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place over 6 hours. Julie Jones, was present throughout. The Registered Manager, Mrs Before the inspection the information about the home was received from the Annual Quality Assurance Assessment (AQAA) submitted by the home and survey responses received from two GP’s and two relatives. The last inspection report was reviewed and all correspondence since the last inspection. The accumulated evidence for this report comes from the above and also fieldwork that included the following: discussions with 8 residents, 1 relative, and 5 staff; observation of practices, tour of the premises, review of documents relating to care, recruitment and health and safety; review of policies; inspection of medication records and storage. Surveys had been sent to 12 residents and none had been returned. Of the 12 surveys sent to relatives two were returned. Both said they “felt welcomed at the home and that they were consulted regarding their relatives care and needs”. Comments included “the staff are very friendly and welcoming”, “the staff’s kindness and care help my relative to settle in”. Surveys were sent to 5 Health Care Professionals that visit the home and responses were received from 2 GP’s. Both said, “the home communicates clearly and provides an excellent service with caring staff”. All residents and staff spoken with told the inspector that the home was very good and the staff very kind. Comments received were “it is very homely and comfortable”; “I would recommend it to anyone”, “they look after me very well”. What the service does well: The staff work well as a team and ensure the well-being and comfort of the residents’ and treat them with great respect and kindness. For example 5 residents spoken with said, “the home is lovely.” “The staff are kind and caring, and the food is good.” There is a good rapport between staff and residents and occupancy level are consistently high. People living at the home feel valued and cared for. Staff feel well supported and enabled to provide a high standard of care. Meals are varied, healthy and nicely presented offering choice and variety. Somerset House DS0000008057.V344473.R01.S.doc Version 5.2 Page 6 Residents’ health and personal care needs are well met by knowledgeable staff in an understanding way. Residents feel that if they had something to complain about they would speak to a member of staff. All residents spoken with said they had nothing to complain about. One resident said ‘the home is excellent, I would recommend it to anyone”.’ What has improved since the last inspection? What they could do better: Assessment of need prior to admission is currently documented but could be improved with fuller information being recorded. Care plans contain some information relating to psychosocial care but continue to be written in a task orientated manner. The documentation of a person centred approach would enhance the care given. Medication practices are adequate but do not provide consistent safeguards during the administration process. A review of this process to ensure that all safeguards are always maintained is required. Staff have a good understanding of abuse but have not received specific training in this area. Staff should receive training to ensure they have a good knowledge and can take the most appropriate action should they suspect abuse. The provision in the home of a Whistle blowing policy would support them in this. The laundry facilities do not afford provision of a sluicing area for soiled linen. The environment needs to be reviewed to ensure that the area is hygienic and systems in use to prevent the spread of infection. Staff receive training but annual updates in mandatory training areas is needed to ensure the continuing competence of the staff. A record of this should be maintained. Somerset House DS0000008057.V344473.R01.S.doc Version 5.2 Page 7 The Quality Assurance system enables the home to access the views of residents and their relatives but does not show how these comments are taken and used in the development and delivery of the service for the benefit of the residents. 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. Somerset House DS0000008057.V344473.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Somerset House DS0000008057.V344473.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. 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. 1,2,3,4,5 The Statement of Purpose and Service User Guide is comprehensive and provides prospective residents with information to make an informed choice. The home’s assessment process is satisfactory and ensures that it is able to meet residents’ needs. EVIDENCE: Residents are provided with a comprehensive Residents’ booklet containing the Statement of Purpose and all the information required to ensure they, or their relatives, have access to the relevant information at all times. The Statement of Purpose includes information regarding equality and diversity issues and the homes antidiscriminatory practices. All residents spoken with had a copy of this in their rooms. Somerset House DS0000008057.V344473.R01.S.doc Version 5.2 Page 10 All residents were aware they had a contract of residency and were happy with the provision that they receive. The contract does not state the room to be occupied for purposes of clarity. On inspecting the Terms and Conditions of residency document the weekly fees to be charged are clear, but it does not show who contributes what amount to make up the weekly fees. This should be included for clarity for residents and their relatives and in line with the recommendations of the recent “Fair Price for Care report”. An assessment procedure for new residents is undertaken but is minimal in the information recorded. The assessment procedure covered aspects of the resident’s day-to-day life, and general needs such as dietary preferences, mobility and dexterity, incontinence etc. The assessment was biased toward measuring the resident’s physical needs with little emphasis on the psychological aspects of care, e.g. the anxieties of moving home or leaving a house. In discussion with two residents that were case tracked this had been well managed and a person centred approach used, however it was not evidenced in the assessment or care plan documentation. The residents’ when spoken to said ‘I am well looked after; they know what I need”. “I am getting used to it and the staff are interested in me, and helping me a lot.’’ Social services care plans had been obtained where relevant. Care practices observed showed that staff were fully aware of the residents needs as stated in their assessments. Somerset House DS0000008057.V344473.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. 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. 7,8,9,10 Care plans provide information for staff to meet resident’s needs in a taskorientated manner, and do not reflect the person centred approach of the home. Personal and environmental risks are well managed. Medication administration and practices are satisfactory. Respect and dignity are well maintained by kind and caring staff. EVIDENCE: Individual records are kept for each of the residents, which include all key personal information. Three care plans were inspected and all reflected clearly current identified health needs. Psychological and social needs were poorly documented and did not reflect a person centred approach to meeting care needs. The three residents were case tracked and all spoke of how the staff at the home had responded to their social and psychological needs in a positive and understanding manner. Somerset House DS0000008057.V344473.R01.S.doc Version 5.2 Page 12 One gave the example of how she had extended her trial stay at weekly intervals, and gradually, in discussion with the staff, had come to the conclusion to sell her home and move in. She said, “the staff were very kind and talked with me. They acknowledged that I had to make the decision in my time and did not pressure me. They were lovely”. Staff when interviewed were clearly able to describe all the needs of the residents being case tracked and demonstrated a person centred approach to care. This is good practice but is not evidenced in care records. Evidence was seen of regular visits by the chiropodist and optician, and residents being taken to other appointments as needed. Resident’s comments supported this. Monthly evaluation of care plans was seen but no evidence of resident involvement with these was seen. Residents spoken with were unaware of their care plans. Staff interviewed said they did discuss residents’ care with them but did not formally record it in the care plan. Thus the person centred approach of the home is not clearly evidenced in the care documentation. Residents said that staff promptly reported to seniors if they have any problems that require attention, and that staff who come on duty later are always up-to-date with their needs. All care plans contained well-formulated risk assessments for falls and any environmental risks e.g. use of the stair lift. Other personal and environmental risk assessments were present to ensure the safety of the resident while promoting independence as able. Daily records seen were respectful and contained relevant information to care needs and provision. Care practices observed showed caring interactions and good communication skills from staff. Choices and preferences were observed being discussed and offered. Medication storage, receipt and disposal are well managed. The home uses the “Nomad system” of medication administration. A full audit trail of medicines entering and leaving the home that are not supplied in the Nomad packs is possible. Medication received into the home in Nomad packs is not recorded for audit purposes. The manager and her deputy write up, and sign, the medication administration records kept by the home on a monthly basis. Medication practices observed were satisfactory but do not fall within the good practice guidelines, as medication is not dispensed directly from the Nomad pack to the resident. The manager is reviewing medication administration practices to ensure adherence to the good practice guidelines. Staff interviewed had received some medication training but had not been competency assessed. They were aware of the potential for errors in the current administration system. Somerset House DS0000008057.V344473.R01.S.doc Version 5.2 Page 13 Hand transcribed prescriptions were seen and these had been signed by two members of staff when written. The home does not have a policy for the administration of homely remedies. The manager understood the need for this and is planning to access the North Somerset PCT policy and discuss and agree it with the local GP’s. All residents spoken with felt that kind and caring staff respected their dignity and privacy. The home has an Equality and Diversity policy that recognises the cultural and social needs and differences that are present in society. Staff have received specialist training in meeting the needs of residents with sight impairment, and evidence was seen of both practical and personal implementation of their learning. In practical terms coloured glasses are being purchased to enable residents to more easily see their drink. Staff observed in helping a resident with sight impairment showed patience and understanding of the residents needs when accessing her food. Both management and staff demonstrated clear knowledge and desire to meet cultural and diversity needs as and when they should arise. Somerset House DS0000008057.V344473.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. 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. 12,13,14,15 Residents’ benefit from routines, and menus, that are flexible to meet their needs. A variety of activities is offered, and residents right to choice and control over their lives is well respected, and encouraged. Friendly staff always welcome relatives and visitors. EVIDENCE: All residents were able to tell the inspector the name of their key worker and the sort of tasks their key worker does for them. They described very warm relationships with the staff. A range of activities is provided with posters displaying information of forthcoming events in the front hall. Two residents said, “there is something on every day of the week if you want it”. Special activities are arranged at varying points of the year. The recent highlight for residents was the summer garden party. Two residents said how much they had enjoyed it and what good links they had with the local community. All residents spoken with enjoy the weekly outings arranged on a Monday. Somerset House DS0000008057.V344473.R01.S.doc Version 5.2 Page 15 The atmosphere in the home was lively and all residents appeared to be enjoying themselves. Residents told the inspector they can see their visitors at any time and that routines are flexible. Residents said that they are given help promptly, and that staff always come quickly if they ring their call bells. Relatives were seen popping in during the course of the inspection and being welcomed by staff. One relative said, “I feel quite happy coming here and the staff are very good to me”. Comments made by relatives indicated that they were made welcome; “there is always a warm welcome when I visit”. A friendly banter was evident between staff and residents throughout the inspection. The dining room is homely and tables well presented. All residents said they liked the meals and felt that they provided a good balanced diet. The menus show a varied and interesting balance. The cook talks to each person about their meal preferences and any menu ideas. She regularly sees the residents to get more feedback. All meals are home-made from fresh ingredients. In addition to the usual cups of tea and coffee, a choice of cold drinks was regularly offered throughout the day. Somerset House DS0000008057.V344473.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. 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. 16,17,18 Residents are confident that they are listened to and their requests acted upon. Knowledgeable and competent staff protect residents. EVIDENCE: The home has a comprehensive complaints procedure and all residents have a copy of it. There have been no complaints since the last inspection. Residents stated that if they were not happy about anything they would speak to the manager. Residents said that the manager and staff are very approachable and they would always raise any niggles with them. Two residents, who said they had done this, were very satisfied with the outcome. Staff and residents spoken to, say the manager is very approachable and understanding. One resident said ‘I’ve nothing to complain about, it’s just like home – we are one family”. A system for keeping clear records of complaints received with actions taken and outcomes are available should any complaints be received. The home has a copy of the North Somerset ‘No Secrets’ Guide. A procedure for responding to allegations of abuse is available and staff were aware of it. Somerset House DS0000008057.V344473.R01.S.doc Version 5.2 Page 17 Staff have not received any formal training regarding Safeguarding Adults and the how to whistle blow should the need arise. All residents said, “The staff are very kind and take time”. “I can’t fault them”. Somerset House DS0000008057.V344473.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. 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. 19,20,21,22,23,24,25,26 Residents are provided with homely, safe and comfortable surroundings. Outdoor space is attractive and accessible for residents to enjoy. The home has suitable equipment to maximise resident independence. Satisfactory Infection Control practices are followed. EVIDENCE: The home is nicely decorated and well maintained with a welcoming atmosphere, and made comfortable with homely communal spaces. It is an adapted period building that has been tastefully enlarged to provide a number of rooms on the ground floor. The home is light, airy and furnished to a good quality. Access to rooms on the first floor is by a stair lift. Residents’ rooms are personalised and comfortable. All rooms are provided with vanity units. Somerset House DS0000008057.V344473.R01.S.doc Version 5.2 Page 19 The décor, fixtures and fittings are in good order. The lounges are furnished with a variety of suitable and comfortable chairs to suit residents’ needs. The home has a large walled garden that is well maintained. Three residents said how much they liked being able to sit out and enjoy it in the summer. The home has grab rails situated at relevant points and a stair lift that is easily used to assist resident mobility, and aid independence within the home. All resident rooms are provided with a lockable space for securing personal possessions if desired. The home was clean and free from offensive odours throughout. All communal washbasins had antibacterial soap and alcohol gel provided. A mixture of linen and paper towels were seen in these areas. The use of paper towels only in communal areas would reduce the potential for spreading infection. Staff interviewed and observed demonstrated good understanding of Infection Control procedures and practices, and maintained a clean and hygienic environment. The home has good facilities for ensuring that staff can maintain good hand washing practices, between caring for residents. The laundry facilities are housed in an outbuilding that is also used to store garden equipment. The environment is dirty and dusty, with floors and walls that do not have washable surfaces. A boiler is also housed in this building and there were cobwebs and other debris rendering the potential for cross infection a high risk. A wash hand basin is provided but this was dirty and did not have soap or towels to allow for good hand washing practice for the prevention of cross infection. The manager said that the laundry is to be redecorated soon. Somerset House DS0000008057.V344473.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 27,28,29,30 The home’s staffing levels are sufficient to manage the care needs of residents. The procedures for the recruitment of staff are robust and provide the safeguards required for residents’ protection. Staff do not receive regular training to ensure best practice care provision. EVIDENCE: Staff went about their duties in an unhurried manner and were observed spending time talking with residents. Residents reported, “staff make time for a chat when they can.” Staff approached residents with directness, openness and consideration. Each of the resident’s with whom the inspector spoke said, “ the staff are very good”. Copies of two weeks staffing rotas were seen. Staffing levels are satisfactory for the number of residents. A sufficient team of ancillary workers supports care staff to ensure the smooth running of the service. Residents spoken with told the inspector “staff are always there when you need them”; “you only have to ring the bell and they come”. Somerset House DS0000008057.V344473.R01.S.doc Version 5.2 Page 21 Staff interviewed said that they were kept busy, but still had time to chat with the residents. While staff were seen to be meeting residents needs and wishes as required, they all had a ‘job card’ for the day, outlining the residents they were to care for and tasks to be done. Staff were very aware of their “job card” and conveyed a task-orientated approach to care. Thus a full person centred approach to care is not implemented. Call bells were answered promptly during the inspection. The home has a Key Worker system in place for all residents. Relatives were aware of the role and said, “it worked well”. Recruitment procedures are robust and both files inspected contained the required documentation. All staff interviewed stated they had contracts of employment and job descriptions. There is a small staff turn over at the home, and all staff said they worked well, as a team and sought to provide a happy atmosphere. Newly appointed staff confirmed they had completed an induction programme and evidence of this was seen. The home provides training but does not keep records of when mandatory update training is needed. There was no evidence of annual mandatory training being provided. Staff interviewed said they had received Manual handling training, first aid and food hygiene but not recently. There was no evidence of these having been provided in the last year. No training plan or records are kept. Staff are therefore not aware of the current best practice guidelines for the provision of care to residents. Evidence of specialist training accessed through the Primary Care Trust and other sources was seen e.g. from the Local representative for the MS Society, and the RNIB over the last two years. All staff who do not have an NVQ qualification are currently undertaking their NVQ 2 training. Interviews with staff showed they had good knowledge with which to meet residents’ needs. Somerset House DS0000008057.V344473.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 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. 31,32,33,35,36,37,38 The manager provides clear leadership and guidance to staff to ensure residents receive consistent care in a safe environment. Quality assurance processes in the home are formal demonstrating that the home consults with residents, families and visiting professionals. The management of resident’s monies in the home are well managed. Health and safety issues are monitored in the home to ensure that issues are identified and addressed where they arise. EVIDENCE: The manager gives clear leadership, guidance and direction to staff. Residents feel she is approachable, available and seeks to ensure all their needs are met. Somerset House DS0000008057.V344473.R01.S.doc Version 5.2 Page 23 Staff interviewed stated that they felt well supported by an approachable manager. A formal quality assurance tool was available for inspection in order to demonstrate that the home consults with residents and relatives. There was no report or evidence to show how these views are acted upon, and used in the development and ongoing provision of the service. Residents felt that their comment were listened to and acted upon. Policies and practice guidance are provided in the home. They are currently being reviewed. Residents’ pocket monies held by the home were inspected and found to be accurate and to have clear records. It is recommended that two signatures for any transactions be made for the safeguarding of all concerned. Supervision for staff is provided both formally, and informally at hand over times and other times, when the staff discuss resident’s care needs and how best to meet them. Records seen were sporadic and did not evidence the practices spoken of by staff and the manager. Records seen showed evidence that care practices for residents and training needs were discussed. Supervision records need to show that supervision is provided at least six times a year. Information received indicated regular safety and fire checks are carried out. Information regarding certificates of safety checks, servicing of equipment and other required safety inspections was supplied. Staff spoken to confirmed that regular fire instruction and drills had taken place. Some fire doors were seen to be ill fitting and others wedged open thus not providing the safeguards required. The manager told the inspector that advice has been sought from the Fire Safety Officer in relation to the safety of the home, and the updating of the Fire Risk Assessment for the home and for any wedged open fire doors for the protection of residents. Somerset House DS0000008057.V344473.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 3 3 3 3 3 3 3 1 STAFFING Standard No Score 27 3 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 2 3 3 Somerset House DS0000008057.V344473.R01.S.doc Version 5.2 Page 25 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. 1. Standard OP26 Regulation 16.2 (j) Requirement To provide laundry facilities that are clean and hygienic to prevent the potential spread of infection. To ensure that all staff receive annual mandatory update training. Timescale for action 30/11/07 2. OP30 18.1 (c) 31/12/07 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. 3. Refer to Standard OP1 OP3 OP3 Good Practice Recommendations The inspector recommends the home consider adopting a more person centred methodology. The current assessment tool is reviewed to evidence a person centred approach to care. That full and clear information is recorded to assist in the care planning process. Somerset House DS0000008057.V344473.R01.S.doc Version 5.2 Page 26 4. 5. OP7 OP10 Care plans are reviewed to demonstrate the person centred approach to care. Medication administration practices are reviewed to ensure all necessary safeguards are provided, at all times, for the protection of residents. All staff to receive Safeguarding Adults training. The home to develop a Whistle blowing policy and ensure all staff are aware of it. To produce a Quality Assurance report to demonstrate how the resident and relative responses are taken into the development and running of the service. Supervision records to be kept up to date to evidence the regular supervision that takes place. 6. OP18 7. OP33 8. OP36 Somerset House DS0000008057.V344473.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Regional Office th 4 Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Somerset House DS0000008057.V344473.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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