Inspection on 05/04/06 for Summerhouse

This inspection was carried out on 5th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Summerhouse 23/01/09

Summerhouse 07/02/07

Summerhouse 08/12/05

Summerhouse 09/06/05

Similar services:

21 High Street

Vale House

Chestnut Walk

The Old Vicarage

Cherwood House Care Centre

Ashley House

Ascot Nursing Home

Fountain View

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

CARE HOME ADULTS 18-65 Summerhouse Summerhouse Guyers Road Freshwater Isle of Wight PO40 9QA Lead Inspector Annie Kentfield Unannounced Inspection 5th April 2006 10:45 Summerhouse DS0000063530.V289530.R01.S.doc Version 5.1 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 Summerhouse DS0000063530.V289530.R01.S.doc Version 5.1 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. Summerhouse DS0000063530.V289530.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Summerhouse Address Summerhouse Guyers Road Freshwater Isle of Wight PO40 9QA 01983 755184 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) Make All Ltd Care Home 11 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (11), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (4) Summerhouse DS0000063530.V289530.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th December 2005 Brief Description of the Service: Summerhouse is a registered care home providing care and accommodation for up to eleven adults with mental health needs, up to four of whom may be over sixty-five years of age. The home is a large detached house in a residential area and not distinguishable as a care home. The home is situated in Freshwater and is near all amenities, bus routes, the town and Freshwater Bay. The home is suitable for mobile service users only as there are steps to the front door and no lift to the first floor. Many of the service users have lived at the home for a number of years and have regular contact with Health and Social Services professionals. The home is owned by Make All Ltd, proprietor Mrs K Toor, who took over the home in April 2005. A new manager was appointed in 2005 but is not yet registered. Summerhouse DS0000063530.V289530.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over 6 hours on a Wednesday and included a tour of the building, discussion with residents, staff and manager, and inspection of some of the home’s records including care plans, medication records and staff records. The manager of the home is not yet registered and the registered owner is required to ensure that an application to register the manager is made to comply with the Care Homes Regulations 2001. This requirement has not been met from the previous inspection. Inspection comment cards were left during the visit for residents and visitors to complete and return if they wished to. What the service does well: What has improved since the last inspection? Since the last inspection the settee and chairs in the lounge have been replaced, as the old ones were very worn. This is a temporary change as the proprietor plans major refurbishment and decoration of the home. The dining room has become the smoking lounge and residents eat in the kitchen or part of the non-smoking lounge. This provides residents with both a smoking and non-smoking lounge with a television in each. Summerhouse DS0000063530.V289530.R01.S.doc Version 5.1 Page 6 Old furniture that was waiting to be removed from the side of the house has been taken away since the last inspection. The shower stool in the downstairs bathroom has been replaced. There has clearly been work done on improving record keeping in the home since the last inspection and the way that care plans and risk assessments are recorded, however, in discussion with the manager, it was agreed that care plans and risk assessment/management plans need further development in order to demonstrate that the home is meeting the National Minimum Care Standards. What they could do better: 1. The manager must apply to the Commission for registration. (This was a requirement from the previous inspection) 2. The home must improve its record keeping procedures; particularly medication administration and care plans/risk assessments. (These were requirements from the previous inspection) 3. Care staff must receive an approved induction training programme and ongoing training in all aspects of safe working practice. (This was a requirement at the previous inspection) 4. It is recommended that the manager should consider introducing a key worker system. (This was a recommendation from the previous inspection) 5. The manager and registered owner must demonstrate how they will gather residents’ views and opinions about the service provided as part of the home’s quality assurance system. (This was a recommendation from the previous inspection) 6. It is recommended that urgent consideration be given to providing the manager with some office space to work in. The manager and registered owner/provider have failed to meet some of the requirements from the previous inspection. Of particular concern it was noted that there are still errors in the medication administration record sheets. Immediate action is to be taken for the manager and staff to receive professional advice and guidance from a pharmacist on the administration of residents’ medication. Staff training in the safe administration of medication must be arranged. Although the manager is in day-to-day charge of the home, she is not registered, and the registered owner must be responsible for ensuring that the home is meeting the National Minimum Care Standards and is compliant with the Care Homes Regulations 2001. Failure to meet the requirements of the Care Homes Regulations 2001 has the potential to put the health, safety and welfare of the service users at risk. Summerhouse DS0000063530.V289530.R01.S.doc Version 5.1 Page 7 The Commission will consider further action if the registered person fails to fully comply with the requirements of the Care Homes Regulations 2001. 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. Summerhouse DS0000063530.V289530.R01.S.doc Version 5.1 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 Summerhouse DS0000063530.V289530.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The manager is in the process of assessing the care needs of a prospective new resident. EVIDENCE: The manager is aware of the home’s categories and conditions of registration. The prospective resident has been invited to visit the home and stay for a weekend trial period if they want to. Discussion with the residents confirmed that they have had the opportunity to meet the new resident. The manager explained that a ‘welcome pack’ has been developed for new and existing residents with information about the home. The home has a pre-admission assessment form and the manager has started to complete this with the prospective resident. More information needs to be gathered before admission, about the care needs and aspirations of all new residents so that the home is clear that individual care needs can be met. The initial assessment of care needs must provide the basis of the individual care plan and risk assessment/management plan for each resident. Summerhouse DS0000063530.V289530.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Quality in this outcome area is poor. This judgement has been made using the available evidence including a visit to this service. All of the residents have individual files that contain all care information, however, there is a need to review this information to ensure that only the most up-to-date and relevant information is easily available to guide care staff on the care to be provided. More work needs to be done to link risk assessments and how risks are managed with the individual care plan for each resident and demonstrate that this is carried out in consultation with the individual residents. EVIDENCE: The inspection looked at three care files. In discussion with the manager it was agreed that the current system of two files per resident could be confusing for care staff that may be new to the home. Whilst all information is contained in the files, the relevant care plan is not immediately accessible. Summerhouse DS0000063530.V289530.R01.S.doc Version 5.1 Page 11 Risk assessments are recorded, however, in discussion, and following on from the previous inspection requirement, it was agreed that the risk assessments recorded do not provide sufficient evidence that residents are consulted with or supported to take informed risks as part of an independent lifestyle. The risk assessments should record how risks are managed and how residents make decisions about their lives with assistance from the staff. The risk assessments should give clear guidance on how risks are managed, what signs, symptoms or triggers are indicated for each resident, and what action staff need to take. It was evident from discussion with the manager and staff, that staff are very knowledgeable about the care needs of the residents and are aware of how residents need to be supported and encouraged, however, this must be recorded and regularly reviewed with the residents to demonstrate that the home is meeting the identified and changing needs and choices of the residents, and meeting the National Minimum Care Standards. It is again recommended that the home consider developing a key worker system for each resident, involving the residents in choosing their key workers. The inspector also spent some time discussing with the manager the recommendation to develop a ‘person centred’ approach to care planning that offers the opportunity for residents to be fully involved in identifying personal goals in their individual plan. Care plans and risk management plans could be more clearly linked to planned care reviews with other health and social care professionals and CPA reviews. There are occasional residents’ meetings but records showed that only two meetings have been held in recent months and these meetings are fairly informal and unstructured. Residents do make choices about their daily lives informally and on an individual basis and this was evident from discussion with residents and observation during the inspection. The manager could consider good practice in developing formal ways of consulting with residents that offer all residents the opportunity to participate in all aspects of life in the home. At the previous inspection the manager was going to explore options for residents to have greater control of their personal finances. This has not yet been addressed. The manager also needs to ensure that the name of the previous proprietor is removed from building society/bank accounts held in the names of some of the residents. Summerhouse DS0000063530.V289530.R01.S.doc Version 5.1 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 and 17 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Residents spoken to said that they had the opportunity to take part in activities that they liked and were happy with the meals provided in the home. EVIDENCE: It was evident that residents are involved in a number of activities of their choice both inside and outside of the home. Some of the residents like to help with daily tasks such as cleaning or laying tables for meals and many of the residents go out independently to the shops or other local activities or the local day centre. Outings are occasionally arranged and the home has transport that some of the staff can use. There is a flexible and informal approach to meeting individual social needs as they arise. Some of the residents expressed a wish to have more shopping trips arranged with staff support and in discussion with the manager it was agreed that a more formal system for arranging residents’ meetings could provide an Summerhouse DS0000063530.V289530.R01.S.doc Version 5.1 Page 13 opportunity for trips and outings to be discussed and agreed with equal opportunity given to all of the residents to participate if they want to. Discussion with the residents confirmed that they were very happy with the meals provided. Breakfast time is flexible and main meals are at set times although meals will be saved if residents are out. Drinks and snacks and fruit are available throughout the day. Summerhouse DS0000063530.V289530.R01.S.doc Version 5.1 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): 20 Quality in this outcome area is poor. This judgement has been made using the available evidence including a visit to this service. Medication is stored appropriately and the manager confirmed that residents have a lockable drawer in their room to store any self-medication if necessary. The manager must seek professional advice on the correct way to record medication received into the home and the administration of medicines to the residents. It is also recommended that all staff receive accredited training in the safe administration of medicines. EVIDENCE: Although the manager has introduced new procedures for checking the medication administration sheets, it was noted that there were gaps in the daily recording of medication given to the residents. Staff had not signed to confirm that medication had been given or the reason why it was not given. These are serious errors and have the potential to put residents at risk. This was discussed with the manager and a referral has been made for the manager and staff to receive some professional pharmaceutical advice and guidance on their medication procedures. The registered person should also arrange for staff to receive some accredited training in the safe administration of medication that includes basic knowledge of how medicines are used and how Summerhouse DS0000063530.V289530.R01.S.doc Version 5.1 Page 15 to recognise and deal with problems in use, and the principles behind all aspects of the home’s policy on medicines handling and records. Summerhouse DS0000063530.V289530.R01.S.doc Version 5.1 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): 23 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. The manager is now aware that staff recruitment procedures must include a number of satisfactory checks and references before new staff start working in the home. The staff training programme should include training in adult protection awareness to ensure that residents are protected by the home’s policies and procedures. EVIDENCE: The home has not appointed any new staff since the last inspection and the manager confirmed that CRB and POVA checks are now in place for all staff working in the home. The manager is also aware of the need for satisfactory pre-recruitment information and written references to be in place before staff start working in the home. Staff training in adult protection awareness is discussed under the staffing section of the report. Summerhouse DS0000063530.V289530.R01.S.doc Version 5.1 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 and 30 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. Since April 2005 the new owner of the home has undertaken some decoration and refurbishment of the building. There are other areas of the home that need refurbishment and it is recommended that a programme of maintenance and refurbishment be planned to prioritise the work that needs to be done. EVIDENCE: The building is a detached period house in a quiet residential area and offers the residents a safe and comfortable home. The building is suitable for residents who are independently mobile. Since April 2005 the downstairs bathroom and upstairs WC has been refurbished and a new shower installed. The front lounge, hallway and stairs have been decorated and carpeted, and some of the bedrooms have been decorated and refurbished. The kitchen, although serviceable, is in need of upgrading, however, the proprietor has indicated that she plans to re-arrange the downstairs communal area to create a new kitchen and dining room and re-arrange the space Summerhouse DS0000063530.V289530.R01.S.doc Version 5.1 Page 18 upstairs to increase the size of the staff/sleep-in room. The upstairs bathroom is serviceable but is in need of upgrading. Residents indicated that they were happy with their rooms and also happy with the new sitting room arrangement that provides both a smoking and nonsmoking area for residents to sit in. Residents can sit in the front and back garden areas if they choose and there is an area of storage in the back garden that is used by the residents. Bedrooms have a wash hand basin and there are two shared bathrooms. At the time of the inspection some maintenance work was in progress; fitting and repairing some of the curtain rails in bedrooms and bathrooms. The home was clean and tidy. The last inspection required the registered person to complete risk assessments on all radiators and hot pipe-work and arrange for any high risk areas to be covered. The manager demonstrated that a risk assessment has been completed, however, it is further required that risk assessments should be completed on residents’ bedrooms that take into account individual residents’ abilities and mobility. Summerhouse DS0000063530.V289530.R01.S.doc Version 5.1 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 and 35 Quality in this outcome area is poor. This judgement has been made using the available evidence including a visit to this service. There appears to be appropriate numbers of staff on duty to meet residents’ needs. The registered person must demonstrate that the home has a staff training and development plan that meets the needs of the residents. New staff must receive induction training that meets nationally agreed standards. EVIDENCE: There are usually two members of staff on duty during the day time with one person sleeping in at night. The manager usually works from 9.00am to 4.00pm on 5 days per week and works one weekend in four. The home employs someone who also cleans on 5 days per week and also works afternoon/evening care shifts. The inspector spoke to some of the staff that have worked in the home for over a year. One member of staff confirmed that they had done some training in adult protection awareness but had not done any other training; other members of staff had not done any training since starting to work in the home. The manager has started to audit staff training needs and begin staff supervision and appraisals but this is not yet complete and there is no evidence of a staff training and development programme to ensure that all Summerhouse DS0000063530.V289530.R01.S.doc Version 5.1 Page 20 staff are trained and qualified. The last inspection required the registered person to have staff training records in place by 30/1/06 but this requirement has not been met within this timescale. From discussion with staff it is clear that the staff team have a good knowledge of the residents’ needs and residents like the care staff. However, there are gaps in the training provided to staff in all aspects of safe working practice and this must be addressed. All staff should have received this training within six months of starting work in the home. The registered person must also demonstrate that staff have an awareness of adult protection policies and procedures to ensure the safety and well being of the residents. Staff spoken to are keen to undertake training and are able to identify their own training needs, particularly in the area of developing their knowledge of mental health care and this should be addressed in a planned programme of staff training. Staff must also have accredited training in the safe administration of medication. The previous inspection required the home to demonstrate that all new care staff have appropriate induction training and this has not been met within the timescale of 30/1/06. The manager explained that new staff are supervised by senior staff but there is no record kept of a planned induction programme to demonstrate that staff are competent and aware of safe working practice such as fire safety, health and safety, and the home’s principles and values of care. There are regular staff meetings and the manager is in the process of setting up systems of formal staff supervision and these will be looked at during the next inspection. Summerhouse DS0000063530.V289530.R01.S.doc Version 5.1 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, 39, 41 and 42 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. From observation and comments from residents, it is clear that the home is managed and staffed with the best interests of the residents at heart. The home must underpin this commitment by improving their record keeping and staff training programme to ensure that the health, safety and welfare of the residents and staff is promoted and protected at all times. The home must develop an effective system for quality assurance. EVIDENCE: The manager must be commended for her commitment to undertaking a strenuous programme of training in a short period of time since she was appointed to the manager role. The manager is currently doing a City and Guilds college course in mental health studies, as well as the NVQ level 4 in care and the NVQ level 4 registered manager award – she hopes to complete all of these courses by the end of 2006. Summerhouse DS0000063530.V289530.R01.S.doc Version 5.1 Page 22 Although there are a number of requirements arising from this inspection, it is recognised that the manager has worked hard to start setting up new record keeping systems and introduce new systems into the home and these take time and improvements are being made. However, the manager and registered owner must ensure that requirements are met within the agreed timescales. It is clear that the manager has gained in confidence and the inspector observed that the manager has a good relationship with residents and staff in the home. Both residents and staff described the manager as “very approachable” and always available when needed. The manager is supported by the registered owner of the home who visits the home on a regular basis. The owner carries out regular checks to report back to the Commission and these could be developed to check that the home is meeting all of the National Minimum Standards and the home is complying with the Care Homes Regulations 2001. The manager would benefit from having some dedicated space to work in and currently has to work in very limited space in the staff sleep-in room that is too small to accommodate a desk. The manager must apply to the Commission for registration and this will be addressed in separate correspondence. The manager and registered person must ensure through their record keeping systems and staff training that the health, safety and welfare of the residents is promoted and protected at all times. The manager and registered person must develop a system of quality assurance that offers residents the opportunity for their views and experience of living in the home to be listened to and be a contribution to the development of the home. Summerhouse DS0000063530.V289530.R01.S.doc Version 5.1 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 X 2 3 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 X 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 1 X 2 X 2 X 2 2 X Summerhouse DS0000063530.V289530.R01.S.doc Version 5.1 Page 24 YES 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 YA9 Regulation 13 (3)(c) Requirement Risk assessments must state how risks will be managed. This was a requirement from the inspection of December 2005. Medication administration sheets must be fully recorded. This was required at the previous unannounced inspections of June and December 2005. Enforcement action will be considered should this requirement continue not to be met. All staff that administer medication must receive accredited training. This was a requirement from the inspection of December 2005. Staff must receive training in adult protection policies and procedures. Radiators must be individually risk assessed and where a high risk is identified - must be covered. This was a requirement from the inspection of December 2005. The home must be able to demonstrate that all care staff DS0000063530.V289530.R01.S.doc Timescale for action 28/04/06 2. YA20 13 (2) 05/04/06 3. YA20 13 (2) 30/06/06 4. 5. YA23 YA24 13 (6) 23 (2)(p) 30/06/06 30/04/06 6. YA35 18 (1)(a) 30/04/06 Summerhouse Version 5.1 Page 25 7. YA32 18 (c) 8. YA39 24 9. 10. YA41 YA37 17 9 and Schedule 2 undertake appropriate induction and ongoing training. Records must be kept. This was a requirement from the inspection of December 2005. The registered person must develop a staff training and development plan. A copy must be forwarded to CSCI by the given date. The registered person must develop a system of quality assurance. This was a recommendation from the inspection of December 2005. Records must be maintained as required by regulation and as detailed in the inspection report. The manager must apply for registration with the Commission for Social Care Inspection. 30/05/06 30/06/06 05/04/06 12/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 YA24 Good Practice Recommendations The home should consider introducing a key worker system. This was a recommendation from the inspection of December 2005. A planned programme of refurbishment and decoration should prioritise those areas of the home most in need of maintenance and replacement with appropriate timescales for completion. Summerhouse DS0000063530.V289530.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight Ground Floor Mill Court Furrlongs Newport, IOW PO30 2AA 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. Extracts may not be used or reproduced without the express permission of CSCI Summerhouse DS0000063530.V289530.R01.S.doc Version 5.1 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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