Inspection on 26/09/06 for Streatfeild House

This inspection was carried out on 26th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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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 Streatfeild House Cornfield Terrace St Leonards-on-Sea East Sussex TN37 6JD Lead Inspector Caroline Johnson Unannounced Inspection 26th September 2006 10:00a Streatfeild House DS0000067677.V307692.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 Streatfeild House DS0000067677.V307692.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. Streatfeild House DS0000067677.V307692.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Streatfeild House Address Cornfield Terrace St Leonards-on-Sea East Sussex TN37 6JD 01424 439103 01424 438842 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) Streatfeild House Limited Mrs Gillian Clusker Care Home 18 Category(ies) of Learning disability (18), Physical disability (9) registration, with number of places Streatfeild House DS0000067677.V307692.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of service users to be accommodated is eighteen (18). Service users must be aged between eighteen (18) and sixty-five (65) years on admission. All service users will have a learning disability. No more than nine (9) of the service users at any one time shall be physically disabled. 01/02/06 Date of last inspection Brief Description of the Service: Streatfeild House is registered to accommodate eighteen adults with learning and physical disabilities. It is located in St Leonards in an old rectory, in a quiet narrow terrace, next to a church. The house is of historic interest. Accommodation is on three floors and the property is well maintained throughout. Externally there is a large parking area. A bus service to Hastings and the seafront passes near the home and there are a small number of shops within a short walk. Streatfeild House DS0000067677.V307692.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of the inspection process two site visits were carried out the first on 26th September, which lasted from 10.00 until 6.00 and the second on 29th September from 2.30 until 4.30. During the visits there was an opportunity to meet with the majority of the residents, to meet with the manager, deputy manager and with two members of care staff. In addition, on the second visit there was time spent with a relative of one of the residents who was visiting the home. During the inspection a wide range of records were examined including the care plans for three residents and record keeping held in relation to staffing, medication, complaints, health and safety, menus and fire safety. A tour of the building was also undertaken. Following the site visits contact was made with another two relatives to seek their views on the quality of the care provided. Comments from relatives included: `God smiled on us the day we found Streatfeild House’, ‘its fantastic, staff are very friendly and you’re always offered tea’, staff are ‘consistently kind and exceptionally patient’. One relative stated that they did a lot of research before choosing Streatfeild house and they were confident that they had chosen the right home. What the service does well: What has improved since the last inspection? Staff have had training on the subject of dementia so that they can more easily meet the needs of one of the residents. In addition to mandatory annual training, the manager ran in-house training on communication. Various scenarios were set and role-play was used to show good and bad Streatfeild House DS0000067677.V307692.R01.S.doc Version 5.2 Page 6 communication. The home is continually looking for ways to build upon and improve the quality of the care they provide. Three new bedrooms have been built in the basement of the building and they are now registered. Each room has ensuite facilities and they are well decorated. The day centre, which used to run from the basement, is now operated from one of the lounges. This means that one of the residents who previously could not attend the activities is now able to do so. 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. Streatfeild House DS0000067677.V307692.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Streatfeild House DS0000067677.V307692.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The introduction of a user-friendly service user guide will assist prospective residents to make a more informed choice about the accommodation provided. The home ensures that they carry out a detailed assessment of prospective residents’ needs and preparation for any move is always planned in line with the each individual’s needs. EVIDENCE: There is a detailed statement of purpose and service user guide in place. The service user guide is not very user friendly. On the first site visit it was recommended that the guide be redesigned with the resident group in mind. By the second site visit the manager had commenced work on this task and was producing a guide in a pictorial format. Since the last inspection the home had admitted one new resident. They carried out a detailed assessment of the resident’s needs. In addition they obtained an assessment from the placing authority and from the resident’s previous placement. The resident’s sister was also involved in the assessment process and she wrote a pen portrait giving lots of information about her brother’s previous history. As part of the preparation several over night stays were organised and the home wrote an account of each visit, which then went on to inform the care plan that was put in place. Streatfeild House DS0000067677.V307692.R01.S.doc Version 5.2 Page 9 Since admission to the home the resident has become much more ambulant and their communication skills have improved. The resident advised that they are enjoying living at Streatfeild House and their bedroom. They also said that they are getting to know all the residents and enjoys all the activities on offer in the home. Streatfeild House DS0000067677.V307692.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The staff team work together to make sure that care plans are kept up to date and that everyone is kept abreast of any changes made. The residents are encouraged to make decisions and choices and wherever possible, taking into consideration any perceived risks, staff work hard to ensure that the residents’ wishes are met. The delegation of small tasks to residents continues to have a very good impact on the home and on the residents who are all very proud of their contributions to their home. EVIDENCE: Two care plans were examined and they both included very detailed information for staff to follow to ensure that the residents’ needs could be met. Daily records are kept to show progress with goals. Care plans are updated monthly by keyworkers and any changes to be made are highlighted. There is a dedicated member of staff who has responsibility for then updating the care plans. As some of the residents have been in the home for many years there is now no contact with their placement authorities and there is no annual Streatfeild House DS0000067677.V307692.R01.S.doc Version 5.2 Page 11 review held. Some of the residents have six monthly reviews and social workers and relatives are invited to attend. In relation to one care plan there are guidelines for what to do if the resident should experience a seizure. However, there is no information of the type of seizures experienced by this resident. Risk assessments are carried out where there are any perceived risks and advice is included to assist staff in minimising the risk of an accident/incident occurring. Staff spoken with were able to identify the key needs of the residents that they have responsibility for in relation to care planning. They were also able to talk about how residents make choices and decisions. Staff meet with their key clients regularly and they encourage residents to come up with ideas of things they would like to do. One of the residents has asked to have a meal in Hastings so this will be arranged. During the summer this resident asked to go to the Chelsea flower show and this was arranged. Other activities that he enjoys include visiting the science museum and garden centres. The residents all continue to share the responsibility for carrying out tasks around the home. These tasks include laying and clearing tables, emptying the dishwasher and plumping cushions. Each resident has a task, which is geared to their individual abilities and tasks are rotated on a regular basis. The residents talked about the tasks they do and are obviously proud of their contribution to the running of their home. Streatfeild House DS0000067677.V307692.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents have opportunities to attend a wide variety of activities that are meaningful and stimulating. Staff work well with the families of the residents ensuring that they are kept informed of any changes in the well being of their relatives and where needed supporting residents to maintain contact. EVIDENCE: Since the last inspection two of the residents became engaged. The home organised a party to celebrate the event and both residents’ families were invited. As an engagement present both residents were taken to London to see a show and to have a meal. Both stated that they were very happy with the support given to them. All of the residents have the opportunity to have an annual holiday. One of the residents spoken with stated that since the last inspection he had been to America. Others stated that they had also been abroad and some had been to Streatfeild House DS0000067677.V307692.R01.S.doc Version 5.2 Page 13 Camber Sands and Bognor Regis. One of the residents stated that during his trip to Bognor he was also able to call on a relative who lived in the area. The day centre that was previously operated from the basement of the home is now run from one of the lounges. Staff advised that this has worked well and that they now try to ensure that more of the activities are community based. In addition one of the residents who was previously unable to access activities in the basement is now able to participate in many of the activities. It was reported that through staff appraisals some of the staff highlighted that more structure is needed to the day centre activities. The manager and her deputy are now addressing this. A number of residents are supported to attend swimming on a weekly basis. One of the residents continues to work two days a week in a nursery. She advised that she loves the mixture of working two days a week and also being able to take part in the day centre activities. Another resident participates in an Active Arts project, which regularly puts on productions. At the time of inspection he was rehearsing for Cats. A small number of residents attend day centres elsewhere in the community. They make their own lunches every evening for the following day. Those spoken with stated that they choose whatever they would like from the fridge for their sandwiches and if support is needed to make the sandwiches there is always a member of staff present. Some of the residents are able to make use of community facilities independently and they stated that they enjoy going for regular walks and using the local shops. Staff also regularly take residents out for meals, for shopping trips, cinema and theatre outings. One of the staff spoken with advised that it is the keyworker’s role to ensure that contact with relatives in maintained on behalf of residents. This was echoed by the relative of one of the residents recently admitted to the home. They stated that the home asked for family birthdays and important dates. This relative was very impressed and stated that this would be the first time his relative would be able to send cards. There is a four-week menu in place and any alternatives to the menu are recorded. The meal presented on the day of inspection was well presented and looked appetising and well balanced. Residents spoken with stated that the food is very good. The three relatives spoken with as part of the inspection process also echoed this. The manager stated that for a number of residents their likes and dislikes vary from time to time. Staff are proposing to take photos of all the meals provided and this will hopefully assist residents in making more informed choices. In addition the cook will have a list of the meals that residents tend to enjoy more frequently than others. Information will also be kept on care plans and reviewed regularly. Streatfeild House DS0000067677.V307692.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected 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 the service. If there are any doubts about a resident’s health then the home are very good at ensuring that this is checked out as soon as possible. A system for monitoring the temperature in the basement would be advisable to monitor that medication stored remains at an appropriate temperature. EVIDENCE: The manager advised that they would be making alternative arrangements for the residents to receive chiropody. They are also hoping that some of the care staff can attend training so that they can provide this service to some of the residents. All of the staff team recently had training on the subject of dementia. The home has referred one of the residents to the Community Learning Disability Service for advice and support regarding his care. Staff that are responsible for the administering of medications have all received formal training on the subject. In addition they must view a video on the subject. There is also staff medication knowledge training, which is generally part of the home’s induction but all staff are expected to complete this regularly as a refresher. Streatfeild House DS0000067677.V307692.R01.S.doc Version 5.2 Page 15 The majority of the medication is stored in a medication trolley. One resident currently self medicates. Medication records were in order. The home has introduced a new chart for each resident showing a photo of the resident, details of any medication prescribed, the resident’s consent to medication is documented, known allergies and details of the prescribing general practitioner. A returns book is kept showing medication returned and the reason it was returned. The pharmacy stamp is also obtained. Some medications are also stored in the basement of the building. There are three areas in the basement, one a dried food store, another area is where the laundry is carried out and the entrance is space for storage. The basement appeared hot as the tumble drier was on. Attention should be given to monitoring the temperature of the medication cupboard to ensure that medications are always stored below 20°-25°C. Where possible the home makes arrangements for residents to have their medications reviewed at least annually and this ensures that residents do not remain on medication unnecessarily. One of the residents praised the manager and the staff team for being so supportive when they went through a difficult patch earlier in the year. Streatfeild House DS0000067677.V307692.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected 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 good. This judgement has been made using available evidence including a visit to the service. There are good arrangements in place to ensure that anyone wishing to make a complaint can do so. EVIDENCE: The manager advised that there have been no complaints since the last inspection of the home. Residents are given information about how they can make a complaint should they wish to do so. There is also a detailed complaint procedure in place for staff to follow. There have been no complaints or protection of vulnerable adult alerts made to the Commission about the home since the last inspection. All the staff team have attended training on the protection of vulnerable adults and in addition they have looked at a DVD on the subject. Streatfeild House DS0000067677.V307692.R01.S.doc Version 5.2 Page 17 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): 24,25,26,27,28,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The building is well maintained and is decorated to a good standard. Bedrooms reflect the tastes and personalities of the occupants. To ensure the safety needs of the residents, the locks on the three new bedroom doors need to be adjusted or changed to a more suitable type. Fire safety arrangements in the home are good with the exception of fire drills which need to be increased in frequency to ensure that all staff know what to do in the event of a fire. EVIDENCE: A full tour of the home was carried out. Bedrooms are well decorated and are personalised with ornaments, family photos and pictures. In each bedroom there is a chart on the wall reminding the resident of their monthly goals, who their keyworker is and information about what to do if they are unhappy about anything. Since the last inspection three new bedrooms have been registered. At the time of inspection two of the rooms were occupied. The residents occupying the rooms both stated that they `love’ their rooms. They are Streatfeild House DS0000067677.V307692.R01.S.doc Version 5.2 Page 18 spacious, they like having an ensuite and they can more easily entertain their friends. The locks on the three bedroom doors can be deadlocked from the inside and either need to be adjusted or replaced with a more suitable type. There were no locks on the bathroom and toilet facilities. However, by the time of the second visit the manager confirmed that locks had been fitted. One of the baths has been taken out and the room is now a wet room. This was considered more appropriate to meet the needs of the residents accommodated. The manager advised that the wallpaper on the landing and hallways is to be replaced in the coming weeks. Records showed that fire alarms are tested weekly and lights are generally tested monthly. There is a detailed fire risk assessment in place. A fire officer visited the home in February and a number of recommendations were made all of which have since been addressed. In-house fire training was provided in July 2006 and most of the staff attended. Drills are not routinely carried out. An external trainer also provided staff training on fire safety in September 2006. All areas of the home seen were clean and there were no unpleasant odours. The manager advised that the deputy manager carries out regular audits of the cleaning. As a result of a recent audit, night staff now have responsibility for ensuring that the downstairs toilets are cleaned. Streatfeild House DS0000067677.V307692.R01.S.doc Version 5.2 Page 19 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): 32,34,35,36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There is a very stable staff team in place that have had regular opportunities to attend courses to update their knowledge and skills. This is obviously a great asset to the home and to the residents accommodated. EVIDENCE: Recruitment records were seen in relation to one member of staff. A pova first had been obtained initially and a full CRB was also in place. An application form had been completed. Verbal references were obtained but there was no written record of the outcome. Both references were from staff that had worked in a junior capacity to the applicant. Although identification would have been in place in order to complete the CRB checks a copy of the staff member’s birth cert and passport should also be kept on file. Since commencing work in the home the staff member has attended a number of courses and was on their last stage of their induction programme. The manager advised that they recently ran an in-house training session for staff on communication. All of the staff team have had recent training on moving and handling and refresher training has been booked for food hygiene Streatfeild House DS0000067677.V307692.R01.S.doc Version 5.2 Page 20 and first aid. In addition to attending formal training courses staff also have access to DVDs on a wide variety of topics. At the end of each DVD there are a list of questions and scenarios given which need to be completed and returned for verifying before a certificate is given. Three of the staff team have completed NVQ at level three and six staff have completed NVQ level 2. Another member of staff hopes to commence level two in the near future. Staff spoken with advised that they receive supervision on a regular basis. The deputy manager advised that she has been sitting in on supervisions with the intention of eventually sharing the task of providing staff supervisions with the manager. Streatfeild House DS0000067677.V307692.R01.S.doc Version 5.2 Page 21 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): 37,38,39,42,43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home is continually evaluating their performance and looking at ways in which they can improve. Attention needs to be given to ensuring that there is the same level of auditing for some of the health and safety issues. EVIDENCE: The manager is well qualified and competent to run the home. She has completed NVQ level four in management and care. Staff spoken with described the manager as ‘very supportive’. One member of staff stated that they `couldn’t imagine working anywhere else’. They `have worked in the home for a number of years and will continue to do so’. In relation to quality assurance residents are asked to complete an annual satisfaction questionnaire. Satisfaction questionnaires are also left at the Streatfeild House DS0000067677.V307692.R01.S.doc Version 5.2 Page 22 entrance door for relatives and visiting professionals to complete. However, the manager advised that although they regularly receive verbal praise for the work they do they very rarely receive a completed questionnaire. An annual development plan was completed last year and the owner has yet to complete this year’s plan. The manager advised that weekly audits are carried out on the medications and that monthly audits are carried out on quality of the cleaning arrangements. Residents’ finances are checked daily. During the site visit there was an opportunity to meet with the relative of one resident. In addition, as part of the inspection process two relatives were contacted to seek their views on the quality of the care provided. Comments received included `God smiled on us the day we found Streatfeild House’, ‘its fantastic, staff are very friendly and you’re always offered tea’, staff are consistently kind and exceptionally patient. One relative stated that they did a lot of research before choosing Streatfeild house and they were confident that they had chosen the right home. Another relative stated that the food is good, their relative is speaking more, they are going out more and they are also very pleased with all the activities that are provided in the home and the fact that arrangements are being made for their relative to go abroad for the first time. As part of the inspection process comment cards were sent to the home, for completion by residents. Eight comment cards were returned. In each case staff assisted residents in understanding the questions and completing the answers using the residents comments. In all cases the comments were positive. Residents indicated that they are happy, they are able to do the activities that they want to and they are encouraged to make decisions and choices on a daily basis. They also stated that their home is always clean and that there are always enough staff on duty. Hot water temperatures were tested at two outlets and both were within agreed safety limits. The home has not yet has an assessment carried out to test for Legionella. Portable appliance testing was carried out in August 2005 and is now due again. The manager was unsure and agreed to check with the owner when the last electrical wiring certificate was obtained. In some of the bedrooms window restrictors had been removed to air the bedrooms. This was considered appropriate because the majority of the residents do not use their rooms during the day. However, there was no risk assessment in place in relation to this. By the time of the second site visit the manager advised that window restrictors are now being kept on at all times. Following the last inspection the owner completed a few monthly reports on the conduct of the home. However, these have not been completed for a number of months now. Staff, residents and relatives spoken with all confirmed that the owner is in the home regularly and keeps up to date with any changes. Streatfeild House DS0000067677.V307692.R01.S.doc Version 5.2 Page 23 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 4 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 2 X 3 3 2 X X 2 2 Streatfeild House DS0000067677.V307692.R01.S.doc Version 5.2 Page 24 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 YA6 Regulation 13(4c) Requirement Information must be obtained from one of the resident’s relative about the type of seizure experienced by their relative so that this can be included in their care plan. The home must monitor the temperature of the medication storage in the basement to ensure it is stored below 20° 25°C. The locks on the three new bedroom doors must be adjusted or replaced to a more suitable type. The frequency of fire drills must be increased to ensure that all staff have the opportunity to take part in a drill. In relation to the recruitment file seen, two written references must be obtained for staff employed to work in the home. A record must also be kept of identification provided, which should include a copy of a birth cert and if possible passport. In relation to health and safety the following must be carried out: DS0000067677.V307692.R01.S.doc Timescale for action 15/12/06 2. YA20 13(2) 20/11/06 3. YA24 13(4a,c) 30/11/06 4. YA24 23(4e) 15/12/06 5. YA34 19 Sch 2 para. 2,3,5 30/11/06 6. YA42 23(2b,c) 30/12/06 Streatfeild House Version 5.2 Page 25 7. YA43 26(2,3,4) Portable appliance testing, Legionalla assessment, Owner must confirm that there is an electrical wiring certificate in place. The owner must carry out a 30/11/06 monthly check of the home and record the result of his findings. The outcome must be available for inspection. 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 YA6 Good Practice Recommendations In addition to the regular reviews carried out by the home, annual reviews should be arranged for residents. An invitation should be sent to the placement authorities to attend and if they chose not to attend a copy of the minutes should be sent to them. The relative’s satisfaction questionnaire should be distributed to relatives to formally seek their views on the quality of the care provided in the home. In addition the home’s annual development plan must be updated. 2. YA39 Streatfeild House DS0000067677.V307692.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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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