Inspection on 15/08/07 for Somewhere House

This inspection was carried out on 15th August 2007.

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

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

Other inspections for this house

Somewhere House 19/09/06

Similar services:

Clouds House

Closereach

Westcliffe House

Hilldales

Longreach

Chandos House

Cherry Orchards Camphill Community Ltd

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

CARE HOME ADULTS 18-65 Somewhere House 68 Berrow Road Burnham on Sea Somerset TA8 2EZ Lead Inspector Kathy McCluskey Unannounced Inspection 15th August 2007 10:00 Somewhere House DS0000067022.V344624.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 Somewhere House DS0000067022.V344624.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. Somewhere House DS0000067022.V344624.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Somewhere House Address 68 Berrow Road Burnham on Sea Somerset TA8 2EZ 01278 795236 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) Somewhere House Limited Angie Clarke Care Home 12 Category(ies) of Past or present alcohol dependence (12), Past or registration, with number present drug dependence (12) of places Somewhere House DS0000067022.V344624.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate one named service user over the age of 64 years, as detailed in the variation application received on 4th August 2006 23/01/07 Date of last inspection Brief Description of the Service: Somewhere House is a large Victorian style property in a residential area of Burnham on Sea. It is close to a range of local amenities, including relevant support groups. The house has been adapted to provide single, double and triple bedrooms in keeping with the supportive nature of this type of service. There is also a group room, provision for individual work, domestic kitchen, laundry and indoor and outdoor communal areas. Somewhere House provides support for adults recovering from drug and alcohol misuse, usually for up to a 6-month stay. Addiction workers, support workers and volunteers support Service users. Somewhere House is registered with the Commission for Social Care Inspection for up to 12 people between the age of 18 & 65yrs. The home is not registered to provide nursing care. Somewhere House is owned by Somewhere House Ltd. Angie Clarke is one of the directors and the registered manager. The home was first registered in April 2006. The home charges are £510 per week. Service users manage their own finances and are responsible for purchasing their own person items such as toiletries, newspapers etc. Somewhere House DS0000067022.V344624.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of this inspection visit was to inspect relevant key standards under the Commission’s ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are; - excellent, good, adequate and poor. This was the home’s second key inspection since it was registered by the Commission in April 2006. The home’s first key inspection was carried out on 19th September 2006. A further random inspection took place on 23rd January 2007 by a CSCI regulation inspector and pharmacist inspector, to follow up on requirements raised. All requirements were found to have been addressed. This key inspection was conducted by CSCI regulation inspector Kathy McCluskey over one day (4.75hrs). The registered manager and deputy manager were available for the duration of the inspection. Pre-inspection information was completed by the registered manager and sent to the Commission. The Commission sent comment cards to healthcare professionals, staff and service users but not have been returned. Any comments will be used for the next inspection. Eleven service users were living at the home at the time of this inspection. The inspector was able to meet with service users and staff and all were very welcoming and appeared comfortable talking to the inspector. The inspector would like to thank the service users, staff and management team for their time and cooperation throughout the inspection process. This was a positive inspection where no requirements were raised. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. What the service does well: Somewhere House provides a rehabilitation service for up to twelve people of either sex and between the age of 18 and 64yrs, who are recovering from drug or alcohol addiction. Somewhere House DS0000067022.V344624.R01.S.doc Version 5.2 Page 6 Somewhere House offers a homely environment which is clean, well maintained and comfortably furnished. Prospective service users are fully assessed and can visit the home prior to a placement being offered. All service users are aware of the routines of the house are fully involved in all aspects of life at the home. Service users are fully involved in the care planning process. Care plans promote a very person-centred approach to care. Service users are supported to take informed risks as part of their agreed plan of care. The home has robust policies in place regarding confidentiality. Service users informed the inspector that all staff at the home treated them with respect and that, ‘they are always there for you day or night’. All confirmed that they ‘felt safe’ at Somewhere House. As part of their agreed treatment and recovery programme, service users benefit from regular group therapies and individual counselling sessions which are provided by suitably trained/qualified staff at the home. Service users stated that the support they received was ‘excellent’. Service users have free time and, in line with any agreed restrictions, can choose how they spend this time. Service users informed the inspector that they really enjoyed their weekly ‘group activities’. The activity, which is decided by service users, takes place each weekend with staff support. Service users informed the inspector that recent events have included bar-b-ques, trips to the beach, walks and swimming. Service users are supported to access appropriate healthcare professionals. The home is effectively managed and the registered manager promotes a very inclusive style of management. The home follows the correct procedures to ensure the health and safety of service users. Appropriate systems are in place to reduce the risk of harm or abuse to service users. What has improved since the last inspection? Requirements raised at the last key inspection were found to have been addressed at the random inspection which was conducted on 23rd January Somewhere House DS0000067022.V344624.R01.S.doc Version 5.2 Page 7 2007. These related to staff recruitment procedures, medication and quality assurance. 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. Somewhere House DS0000067022.V344624.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Somewhere House DS0000067022.V344624.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5 Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. Somewhere House ensures that prospective service users have all the information they need to enable an informed decision about moving to the home. Prospective service users are fully assessed prior to a placement being offered. Service users are provided with contracts/agreements which clearly state the terms and conditions of occupancy. EVIDENCE: The home has produced a Statement of Purpose which is available to service users and prospective service users. The registered manager informed the inspector that there had been no changes to this document since the last inspection. A client handbook is on display in the home. The handbook contains detailed information which include; house guidelines & routines such as cleaning, cooking and laundry arrangements. It also contains useful contact details for local dentists, doctors, churches etc. A copy of the home’s complaints Somewhere House DS0000067022.V344624.R01.S.doc Version 5.2 Page 10 procedure, which includes the contact details of the Commission, and emergency contact procedures for service users is also available. Service users spoken with confirmed that they always had access to the handbook and that they found the information very useful. Somewhere House has a consistent admissions procedure which ensures that all prospective service users are appropriately assessed prior to a placement being offered. Assessments from other appropriate healthcare professionals are obtained where available. Evidence of this was seen in two service user care plans examined. Wherever possible, prospective service users are encouraged to visit Somewhere House so that they can get an insight into the facilities and programmes offered. Existing service users show prospective service users around the home. Service user care plans contained contracts and agreements which had been signed by the service user. Somewhere House DS0000067022.V344624.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 & 10 Quality in this outcome area is Excellent This judgement has been made using available evidence including a visit to this service. Service users are fully involved in the care planning process. Care plans promote a very person-centred approach to care. Service users are fully involved in all aspects of life at the home. Service users are supported to take informed risks as part of their agreed plan of care. The home has robust policies in place regarding confidentiality. EVIDENCE: Two service user care plans were examined in detail at this inspection. On admission, service users are supported to complete a plan of care where their own needs, aspirations and goals are recorded. Service users re-write their Somewhere House DS0000067022.V344624.R01.S.doc Version 5.2 Page 12 care plans on a monthly basis with the support of their counsellor or addiction worker. Care plans therefore, promote a very person centred approach to care. Three service users were spoken with during this inspection and all stated that they found this process very helpful and that their care was individual to their identified needs. Service users are fully involved in all aspects of decision making about their care and how their identified goals will be met. Service users sign up to an agreement where they are expected to gain further support by attending outside groups such as alcoholics anonymous and narcotics anonymous. Workers at the home support service users to attend these groups. Service users confirmed that they found the support very helpful. The inspector was informed that staff also supported them to gain and attend voluntary work placements. Service users informed the inspector that all staff at the home treated them with respect and that, ‘they are always there for you day or night’. All confirmed that they ‘felt safe’ at Somewhere House. The registered manager informed the inspector that the service users run the house as ‘it is their home’. This was evident to the inspector throughout this inspection and was confirmed by service users spoken with, ‘We run the house, do the shopping, cleaning, menus and cooking’. Service users are always made aware of any visitors at the home and are responsible for showing visitors around the home. Service users are also involved in the selection process for prospective staff where their views/observations are encouraged. Service users have their own weekly house meetings. They are responsible for recording the outcome of the meetings. Minutes are passed to senior staff for any action. As part of their programme to recovery, service users have certain restrictions placed on them. Apart from general house rules, restrictions are individual to each service user’s needs and are agreed as part of their plan of care. As previously mentioned, service users are fully involved in this process. Risk assessments are in place where there is an assessed need. Risk assessments were also seen regarding the service user’s ability to selfmedicate. Service users feel confident that any information about them is handled appropriately and that confidentiality is maintained. The home has strict policies in place relating to confidentiality. Service users and staff sign a confidentiality agreement. On arrival at the home, the inspector was asked to read the home’s confidentiality policy. This is the case for all visitors to the home. The home ensures that all information pertaining to service users is handled/stored in accordance with the Data Protection Act 1998. Somewhere House DS0000067022.V344624.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17 Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. The home’s arrangements for enabling service users to develop personal and emotional & daily living skills are very good. Service users are supported to engage in appropriate leisure activities and to maintain links with the local community. Service users are fully involved in planning, shopping and cooking meals. Menu options are varied and wholesome. EVIDENCE: As previously mentioned in this report, the home has clear routines for service users. Service users are responsible for the ‘running of the home’ and are supported as appropriate, to develop or maintain daily living skills. Service Somewhere House DS0000067022.V344624.R01.S.doc Version 5.2 Page 14 users spoken with informed the inspector that they found this very helpful and fulfilling. As part of an individual’s plan of care, the home supports service users to attend groups outside of the home and to access appropriate employment or education placements. Service users manage their own finances though the home support/assist service users with any benefit claims. This was evident at the time of the inspection. As part of their agreed treatment and recovery programme, service users benefit from regular group therapies and individual counselling sessions which are provided by suitably trained/qualified staff at the home. Service users stated that the support they received was ‘excellent’. Service users have free time and, in line with any agreed restrictions, can choose how they spend this time. Service users informed the inspector that they really enjoyed their weekly ‘group activities’. The activity, which is decided by service users, takes place each weekend with staff support. Service users informed the inspector that recent events have included bar-b-ques, trips to the beach, walks and swimming. The arrangements for service users to maintain family links or relationships are detailed and agreed for each individual in their therapeutic contract. The home does not offer placements for couples. Service users informed the inspector that their privacy was respected. Service users are aware of the home’s arrangements regarding random checks of the home and bedrooms. Service users private mail is not opened by the home. As previously mentioned in this report, service users are responsible for devising the menu, shopping and cooking. Service users informed the inspector that each Wednesday night they would get together and plan the menu. Service users agree which two will do the shopping each week. Shopping trips are supported by a staff member. Meals are enjoyed in the communal dining room. This is an inclusive experience where staff eat with service users. Service users have unrestricted access to the kitchen. Somewhere House DS0000067022.V344624.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 20 Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. Service users at the home do not require any staff assistance to meet personal care needs. The home ensures that service users have access to appropriate healthcare professionals. The home’s procedures for the management and administration of service user medication are generally good. EVIDENCE: Standard 18 is not applicable. Service users at the home do not require any staff assistance to meet their personal care needs. When a service user moves to the home, the home ensures that individual’s are registered with a local GP and dentist. As previously mentioned, support is offered to attend appointments in line with the individual’s agreed plan of care. The home supports service users to attend other appointments as necessary. Somewhere House DS0000067022.V344624.R01.S.doc Version 5.2 Page 16 Regular drug tests are carried out by suitable trained staff. Service users agree and sign consent forms when they move to the home. The inspector examined the home’s procedures for the management and administration of service users medication. The number of service users on prescribed medication were very low and the home does not accept service users who are prescribed long term mood altering medication. All medicines were found to be securely stored and are only administered by staff who have received appropriate training. Risk assessments were found to be in place for those service users who were self medicating. As medication administration records are all handwritten, to reduce the risk of errors it has been recommended that all entries are checked and signed by two staff. Currently only one staff member signs the entry. The home should ensure that maximum daily doses are identified for paracetamol. The home has robust daily checking systems in place for all stocks of medication. Records are maintained for homely remedies and the reason for administration is recorded. The inspector was informed that the home does not currently have any medicines requiring refrigeration and that secure storage systems were available should this be required. Somewhere House DS0000067022.V344624.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure in place and the views of service users are encouraged. The home has systems in place to reduce the risk of harm or abuse to service users. EVIDENCE: Service users spoken with confirmed that their views were encouraged and listened to. All were aware of the home’s complaints procedure. A copy of the complaints procedure, which includes the contact details of the Commission, is also available in the service users handbook. All service users told the inspector that they felt safe at Somewhere House. The registered manager confirmed that the home had not received any complaints. No complaints have been raised directly with the Commission. The home has policies in place to reduce the risk of harm or abuse to service users. It has been recommended that the home obtains a copy of Somerset’s revised policy (May 2007) on Safeguarding Adults. The registered manager confirmed that appropriate action would be taken. The home follows robust staff recruitment procedures. Somewhere House DS0000067022.V344624.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 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. Somewhere House provides service users with an appropriate comfortable, homely environment in a convenient location. Service users have access to a range of communal areas including therapy rooms. The standard of cleanliness is good. EVIDENCE: Somewhere House is situated in a convenient location in Burnham-on-Sea, close to the sea, town and local leisure facilities. The home is well maintained, comfortably furnished and promotes a ‘homely’ feel. Somewhere House DS0000067022.V344624.R01.S.doc Version 5.2 Page 19 Communal areas consist of a lounge, dining room, kitchen, laundry. There is also a group room and smaller room which is used for individual counselling sessions. Service users are able to utilise the group and counselling rooms in the evenings. The majority of bedrooms are shared. Some are fitted with en-suite facilities. The use of locks is determined by the type of service provided and it is not appropriate to lock doors, although rooms are locked if a service user is away from the home. The home has an adequate number of toilet/bathing facilities. Service users are responsible for cleaning the home. At the time of this inspection, the standard of cleanliness was found to be good. The home takes appropriate steps to reduce the risk of the spread of infection. Appropriate hand washing facilities, consisting of liquid soap and paper hand towels were seen to be in place. Cleaning materials were found to be appropriately stored. The home is not designed for people who have mobility difficulties. No specialised equipment is available. Stairs give access to the first and second floor. Somewhere House DS0000067022.V344624.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): 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. Service users benefit from a suitably qualified and experienced staff team. There are sufficient staff on duty to provide the level of support needed by the current service users. The home follows robust staff recruitment procedures, which reduce the risk of harm or abuse to service users. The home arrangements for ensuring that staff are appropriately supervised is very good. EVIDENCE: Two staff recruitment files were examined at this inspection and the inspector was able to see that staff are provided with detailed guidelines and job descriptions which clearly identify their roles, responsibilities and limitations. Somewhere House DS0000067022.V344624.R01.S.doc Version 5.2 Page 21 There is clear allocation of responsibilities, including named addiction workers allocated to service users. Volunteers are also engaged at the home who have experience in the type of work and are pursuing counselling training. Files examined evidenced that staff had received appropriate training and induction. Staff complete a learning and development plan where they are encouraged to identify their own training needs. Training which had taken place included; drug awareness, person centred counselling, minimising harm, cognitive therapy, drug checks training, equality & diversity, psychodynamic training, medication training, first aid and fire. The registered manager informed the inspector that all staff have received training in first aid. Pre-inspection information completed by the registered manager identified that 90 of the care staff have an NVQ level 2 or above. Certificated evidence was not checked at this inspection. Service users spoken with were very positive about the staff and their ability to meet individual’s needs. The inspector was informed that the following staff are on duty; registered manager, deputy, addiction worker and support worker. A support worker provides sleep in cover at night. Duty rotas are displayed and the home maintains a clear on-call rota. Maintenance support is provided by on of the home’s directors. No concerns were identified relating to staffing levels at the home. The numbers and skill mix of staff appear sufficient to meet the needs of the service users. Two staff recruitment files were examined at this inspection, one of which related to the most recent member of staff. All required information was available. Documentation seen was detailed and fully completed. The home’s arrangements for staff supervision are very good. In addition to a comprehensive annual appraisal, all staff have monthly supervision sessions. Records and topics discussed were very detailed. Staff are very well supported. Daily meetings are held, as are monthly meetings. Minutes are recorded. The last monthly meeting was held on 27th July ’07. Somewhere House DS0000067022.V344624.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): 37, 38, 39, 41, 42 & 43 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The home is effectively managed by a registered manager who promotes an open and inclusive style of management. Effective quality assurance systems are in place. Appropriate systems are in place and followed to ensure the health and safety of service users. EVIDENCE: The registered manager is Angie Clarke. Angie is also one of the company directors. The Commission approved an application for the service to be registered and for Angie to be registered manager, in April of last year. Somewhere House DS0000067022.V344624.R01.S.doc Version 5.2 Page 23 Angie has over 19 years of experience working with addictions and 15 years of this time has been working in the community mental health team and also the acute teams. Staff and service users spoke highly of the registered manager and of the support and expertise she provided. It was very apparent that the registered manager promotes an open and inclusive style of management. This was ascertained through discussions and an examination of records. The registered manager has introduced a quality assurance system based on service user satisfaction surveys and feedback. All service users are given an exit questionnaire to complete when they leave the placement. The registered manager analyses the responses and an action plan is developed to improve the service delivery. The exit questionnaire is detailed and covers all aspects of the service users’ stay, support programmes and staff. The quality assurance system also includes a business plan for the home. As previously mentioned, monthly staff meetings are held and the views of staff are encouraged. The home follows the correct procedures to ensure that all information pertaining to service users is handled and stored in accordance with the Data Protection Act 1998. As previously mentioned, service users are fully involved in the development of their records. At the time of this inspection, the home is following the correct procedures relating to health & safety; GAS SAFETY – The home has an up to date annual Landlords Gas Safety certificate dated 19/04/07. ELECTRICAL SAFETY – An up to date electrical hardwiring certificate was seen dated 24/03/06 and valid for 5 years. Portable appliances are checked annually by an external company. This was last carried out in September 2006. The registered manager confirmed that personal electrical items brought into the home by service users, are visually checked to ensure that they are safe. FIRE SAFETY – The inspector was able to see evidence that monthly fire drills are conducted. Detailed records are maintained. In addition to this, staff receive formal training on an annual basis. The home checks fire alarms/detection systems weekly. Records seen were up to date. Somewhere House DS0000067022.V344624.R01.S.doc Version 5.2 Page 24 Up to date monthly checks were seen for the home’s emergency lighting systems. Annual servicing by an external contractor was last carried out on 20/06/07. The local fire officer examined the premises on 29/11/06 and the home was found to have a ‘satisfactory standard of fire safety’. No breaches were noted. The home has developed a fire risk assessment which was last reviewed in January 2007. ACCIDENTS – The home completes appropriate records relating to accidents. These are maintained in accordance with the Data Protection Act 1998. The number of accidents were unremarkable and none were noted to be reportable. The registered manager and deputy confirmed that they were aware of incidents to be reported to the Commission under Regulation 37 of the Care Homes Regulations 2001. The registered manager confirmed that all staff working at the home have received appropriate training in first aid. Certificates were seen in those staff files examined. CONTROL OF SUBSTANCES HAZARDOUS TO HEALTH (COSHH) – At the time of this inspection, all cleaning materials were found to be securely stored. Information provided by the registered manager indicated that the home’s policies were reviewed in April ’07. FOOD SAFETY – All staff involved in food preparation have an up to date certificate in food hygiene. The home’s policies were implemented in April ’07. The home displays an up to date employers liability insurance certificate which expires 09/03/08. The home’s business plan was offered to the inspector but this was not required for this inspection. Somewhere House DS0000067022.V344624.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 4 3 3 LIFESTYLES Standard No Score 11 4 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score N/A 3 3 x 3 3 3 x 3 3 3 Somewhere House DS0000067022.V344624.R01.S.doc Version 5.2 Page 26 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA20 Good Practice Recommendations To reduce the risk of errors, the registered person should ensure that all handwritten entries on medication administration records are checked and confirmed by two staff signatures. Maximum daily doses for paracetamol or similar, should be recorded. The registered person should ensure that Somerset’s revised policy (May 2007) on Safeguarding adults is obtained and made available to staff. 2. YA23 Somewhere House DS0000067022.V344624.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Somewhere House DS0000067022.V344624.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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