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Inspection on 07/02/07 for Summerhouse

Also see our care home review for Summerhouse for more information

This inspection was carried out on 7th February 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

From the evidence gained during the inspection process it was clear that Summerhouse is a valued service for people with mental health needs in the West Wight area. It provides a good personalised service for those who live in the home. The manager and staff enjoy good relations with the local community including the mental health day service and specialist healthcare professionals. One visiting community health professional felt one of the home`s strengths was its support for individuals to live the life they choose. Another praised the home for its individualised support for people with chronic mental health illness. Both felt the staff had good skills to meet the needs of the residents.

What has improved since the last inspection?

CARE HOME ADULTS 18-65 Summerhouse Summerhouse Guyers Road Freshwater Isle of Wight PO40 9QA Lead Inspector Neil Kingman Unannounced Inspection 7 February 2007 11:05 Summerhouse DS0000063530.V330069.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 Summerhouse DS0000063530.V330069.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. Summerhouse DS0000063530.V330069.R01.S.doc Version 5.2 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 Elise Rebecca Grimes 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.V330069.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5 April 2006 Brief Description of the Service: Summerhouse is a registered care home providing care support 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 two storey detached period house located in a quiet residential area of Freshwater, close to bus routes. It is less than a mile from the amenities and shops of Freshwater town and the coastal amenities of Freshwater Bay. The building is similar to some other properties in Guyers Road. Summerhouse is suitable only for residents who are fully mobile, as there are steps to the front door and no lift to the first floor. Many of the residents have lived at the home for a number of years and have regular contact with a range of Health and Social Care professionals. Most rooms are for single occupancy and are arranged over the ground and first floors. Currently communal areas consist a lounge, kitchen/diner and a separate smoking lounge. Rooms do not have en-suite facilities. Plans are in place to develop the kitchen, communal and other areas of the home. The registered manager Elise Grimes manages the home on behalf of the proprietor Mrs K Toor of Make All Ltd. Summerhouse DS0000063530.V330069.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report details the results of the second key inspection of Summerhouse since April 2006, and focuses on the home’s response to the requirements and recommendations identified at the last inspection on 5 April 2006. Consultation with people who use the service was limited to those people in the home at the time of the site visit. However, the inspector was able to hold telephone discussions with two visiting healthcare professionals. The responses from those consultations were very positive. Included in this inspection was an unannounced site visit to Summerhouse by an inspector on 7 February 2007. The manager was available and in charge of the home and the proprietor visited during the afternoon. During the visit the inspector spoke with the manager, staff on duty and all residents individually. The inspector toured the building with the manager and looked at a selection of records. Significant improvements on the results of the last inspection were noted. What the service does well: What has improved since the last inspection? All requirements and recommendations identified at the last inspection have been met: • • • • Risk assessments have been reviewed and updated to provide information lacking at the time of the last inspection. Medication administration sheets are recorded appropriately. Staff have received medication training. Individual hot water radiators have been risk assessed. DS0000063530.V330069.R01.S.doc Version 5.2 Page 6 Summerhouse • • • • • A staff training plan demonstrates that all mandatory training is either completed or scheduled. The home has an effective quality assurance system in place. The manager has completed the process for registration. A key worker system has been introduced. A programme of refurbishment of the building is underway. 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. Summerhouse DS0000063530.V330069.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 Summerhouse DS0000063530.V330069.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. To ensure residents care and support needs are met, a proper assessment is undertaken before they move into the home. EVIDENCE: Pre-admission assessment At the last key inspection shortfalls were noted in the home’s procedure for assessing prospective residents’ needs before they moved into the home. At this inspection the manager said that since then a new pre-admission assessment format had been developed to capture all information about the care needs and aspirations of new residents so that the home is clear that individual care needs can be met. The inspector looked at how the home managed the admission of the newest resident, who moved into Summerhouse during April 2006. The manager confirmed that she had undertaken a full pre-admission assessment of the individual’s needs at a mental health assessment centre in Newport. The new assessment form had been used and was signed and dated. It was noted to be clear and comprehensive, covering all the necessary information needed to start a plan of care for daily living. A copy of this assessment was included on the resident’s file. Summerhouse DS0000063530.V330069.R01.S.doc Version 5.2 Page 9 The manager showed a good understanding of the importance of a preadmission assessment, describing how, in the case of the new resident, there had been several introductory visits to the home to establish compatibility with existing residents. Summerhouse DS0000063530.V330069.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Opportunities for residents to make decisions and choices in their lives are determined by assessment and recorded in individually agreed personal plans, drawn up between the home and the residents. Residents are enabled to take control over their lives. Any limitations are identified in the assessment process and recorded in their personal plans. They are encouraged to be as independent as possible and to take sensible risks, which enhance their enjoyment of life. EVIDENCE: Personal plans – Each resident has a personal plan, which identifies residents’ daily needs and wants and details an action plan to meet those needs. At the site visit the inspector looked at a selection of three plans. They cover outcomes for people engaged in activities that are unsupervised, together with specific guidelines Summerhouse DS0000063530.V330069.R01.S.doc Version 5.2 Page 11 for staff around routines. They provide specialist information applicable to individuals. However, while containing a good deal of information found lacking at the last inspection they could still benefit from being more ‘person centred’. This could assist with the assessment of individual risks as described later in the report. The home has responded to the recommendation at the last inspection and introduced a key worker system, which, amongst other things, includes a monthly assessment in relation to: • • • • • • Clothing needs/repairs Health Visits to specialist healthcare professionals Diet/eating/sleep patterns Wellbeing Activities In discussions with residents it was clear that some had knowledge of their plans but showed no particular interest in them. Decision making Information in Personal Plans and discussions with staff on duty provided evidence of them respecting residents’ rights to make their own decisions. Residents meetings have brought up suggestions from residents about activities in the evenings and trips out in the summer. It was a busy day when the inspector visited and residents were coming and going; one attended the local day centre, one visited family, another went out to the shops and others spent time in the home. Communication between residents and staff is good and interactions are good humoured. At previous inspections the manager was going to explore options for residents to have greater control of their personal finances. It was noted at this inspection that three residents are assessed as being able to manage their own finances independently of the home. Following assessment the arrangement for the others involves the home offering a system, which safeguards their monies, while allowing them access to whatever they need and want against signature. Each resident now has his or her own bank, building society or post office account. The inspector looked at the system by way of ‘dip-sampling’ and found it to be in good order. Summerhouse DS0000063530.V330069.R01.S.doc Version 5.2 Page 12 Risk taking – At the last inspection it was identified that risk assessments lacked information about how risks will be managed. Since that time the system of risk assessment has been reviewed and updated. The inspector noted clear and specific risk assessments on residents’ personal plans. They cover the assessment of risks in their rooms (including radiator hot surfaces), risks re: enduring mental health problems and risks around daily routines. They contain action plans agreed with the resident. However, on the day of the site visit the inspector noted one resident was particularly fond of going out alone most days. In discussions with the manager it was evident that there had been occasional problems when the resident was away from the home. This had not been covered in the risk assessment process. Additionally, issues around the same resident falling in the home had not been covered by risk assessment. A more ‘person centred’ approach to planning would help to ensure all individual risks are identified and assessed. Summerhouse DS0000063530.V330069.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): 12, 13, 14, 15, 16 and 17 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged and supported to take part in a range of activities appropriate to their age and individual likes and dislikes. They are supported to maintain regular contact with families, friends and the local community. Routines in the home promote independence for the residents who have unrestricted access around the home. They are offered meals they enjoy, which are varied and healthy. EVIDENCE: Education and occupation The manager said that the assessed needs of most of the residents are such that seeking jobs for them is not appropriate. Voluntary work had been found for one resident, which proved unsuccessful and gardening work for another, Summerhouse DS0000063530.V330069.R01.S.doc Version 5.2 Page 14 which was still ongoing. The manager said that apart from one resident occasionally attending a course in cookery, others had no interest in further education. In discussions with the residents it was evident they were supported to do whatever they wanted. Some are frequent visitors to the mental health day centre in Freshwater where a range of activities takes place. From talking to the manager, staff and mental healthcare professionals, and looking at records that residents receive all the support they need with any problems around finance/benefits. Community links, social inclusion and relationshipsIt was clear from the inspector’s observations and from information in personal plans that residents enjoy going out from the home. The manager said they are well known and liked in the local town. On the day of the site visit several residents spent time outside of the home, returning for meals. One who had been out during the day, returned for the evening meal before going off swimming at the health centre. Staff treat residents as individuals and support them variously to visit local pubs, cafes, swimming pool, bingo and other areas of interest, including day trips during the summer months. The manager described an event to which all residents went as a group. This was unusual, as they had shown no interest in group activities in the past. In discussions with residents the prospect of the home providing a bus travel pass was raised. This was fed back to the manager who was fully aware of the reasons for the request and had looked in depth at the outcomes for one resident in particular. Most but not all residents maintain contact with their families. While visits to the home are welcome and encouraged those residents that do maintain contact tend to visit family away from the home. Meals – All staff take turns in preparing and cooking the meals in the home. This seems to work well in what is essentially a domestic scale setting. Certainly there was unanimous approval of the meals provided. While a number of residents went out during the morning most returned at lunchtime. The inspector noted the meal served looked appetising and residents seemed to enjoy it. Summerhouse DS0000063530.V330069.R01.S.doc Version 5.2 Page 15 Menus showed that food is varied and nutritious. Residents decide what food they like to eat and as the menus are flexible the meals can be changed if an alternative is called for by way of special request. In discussions with the residents it was clear they very much enjoyed the meals in the home. Summerhouse DS0000063530.V330069.R01.S.doc Version 5.2 Page 16 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): 18,19 and 20 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff provide flexible but consistent support for residents and are responsive to their changing needs. They encourage residents to make choices, which reflect their individual personalities. Residents’ healthcare needs are assessed and key workers enable and support them to receive healthcare checks at appropriate intervals. Medication is securely held and appropriate records maintained. EVIDENCE: Personal support – There are currently nine residents at Summerhouse. All are fully mobile and none has a disability that requires aids or adaptations in the home. The inspector noted that they were dressed differently, as one would expect, according to their ages and preferred tastes. Key workers take note of any clothing or toiletry requirements and support the residents to purchase items themselves. Summerhouse DS0000063530.V330069.R01.S.doc Version 5.2 Page 17 Residents are largely self-caring, being able to mange their own personal hygiene, with encouragement in some cases. They confirmed in discussions that they could go to bed and get up when they want. Also, they could remain in their room if they want, as the inspector noted with one resident, where respect for her privacy was particularly important. Respect for residents’ privacy and dignity was noticeable. Staff knocked on doors, and waited for a response before entering. They addressed them by their preferred names. Healthcare – Care records showed that residents’ health care needs are regularly addressed. They receive checks from the GP, dentist, optician and specialist health care professionals. All health care needs of the residents are identified in their personal plans. The manager said that all residents are registered with one of several GPs in the local health centre. Residents are capable of attending the various practices for health checks, either alone or with staff, which include dentist, optician, and chiropody in a few cases. Community psychiatric nurses (CPN) spoken with confirmed that the staff respond well to the residents’ physical health needs. One remarked that the staff are, “absolutely brilliant,” and the home caters very well for people with chronic mental illness. Medication The inspector looked at the home’s arrangements for residents’ medication with the manager. This had been the subject of requirements at the last inspection. The inspector noted all requirements had been met. Since the last inspection all staff deemed competent by the manager to administer medication have received formal training. Certificates were available for inspection. At the time of the site visit medication for residents was securely held in appropriate metal cabinets, and records relating to its safekeeping and administration were found to be in good order. Summerhouse DS0000063530.V330069.R01.S.doc Version 5.2 Page 18 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 and 23 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home treats residents’ complaints seriously and responds appropriately. The home’s policies, procedures and practices ensure that residents are safeguarded from abuse. Procedures for responding to suspicion or evidence of abuse are robust. EVIDENCE: Complaints The home has a formal complaints policy and procedure, which is summarised in the Service User’s Guide. Residents spoken with knew who to go to if they had any concerns. Both community health professionals reported no concerns with the home. The manager said they had received no complaints about the service from residents and was very clear that residents would certainly voice concerns if they had any. The residents meetings were seen as a good forum for raising and discussing issues. Records are kept of the meetings and action is taken where applicable. Adult protection The home has an adult protection policy and procedure, which is linked to the Isle of Wight Social Services guidance. The manager confirmed that all staff were scheduled to attend a Protection of Vulnerable Adults (POVA) basic Summerhouse DS0000063530.V330069.R01.S.doc Version 5.2 Page 19 awareness workshop over the next three months and records were available to support this. Care support workers were very clear about how to recognise abuse, what to do, and the importance of reporting issues of concern without delay. Summerhouse DS0000063530.V330069.R01.S.doc Version 5.2 Page 20 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 and 30 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. While the home’s premises are generally suitable for its stated purpose, there are shortfalls in environmental standards. However, the programme of prioritised refurbishment required at the last inspection is about to be fully implemented. On the day of the site visit the home was clean, hygienic and free from unpleasant odours. EVIDENCE: Premises The building is a detached period house in a quiet residential area of Freshwater and offers the residents a safe and comfortable home. The building is suitable for residents who are independently mobile. There was evidence that significant improvements are about to be made to the environment. Summerhouse DS0000063530.V330069.R01.S.doc Version 5.2 Page 21 At the last inspection a planned and prioritised programme of refurbishment and decoration was recommended. The manager confirmed that the identified priority of work to create a new kitchen and an upgraded first floor bathroom was due to commence on 12 February 2007. Further work was planned for other areas of the home. During the morning the inspector toured the building with the manager and later individual residents invited the inspector to view their rooms. It was noted that all beds and furniture in rooms had been renewed. On the day of the site visit the proprietor arrived with new duvets and pillows for residents’ rooms. Some carpets in rooms had been replaced and the manager confirmed that more would follow. In discussions with residents it was clear that they liked their rooms; one in particular took time to show the inspector what had been bought for the room and the improvements that had recently been made. The resident confirmed that she had influenced the changes made. One of the rooms is shared; an arrangement that has been ongoing for about six years. Both residents were spoken with and confirmed that they were happy with the arrangement. All rooms were noted to be personalised to reflect residents’ individual tastes and hobbies. While there are no en-suite facilities each room has a wash hand basin and there is a bathroom/WC close by. Cleanliness All areas were noted to be clean, tidy and free from unpleasant odours. One care support worker performs the duel role of housekeeping and supporting the residents. The laundry area is currently located between the kitchen and dining areas. However, included in the forthcoming refurbishment of the rear ground floor is a plan to relocate the laundry by creating a utility room. It was confirmed by the manager that when in use soiled articles would not be carried through areas where food is stored, prepared or eaten. Records showed and staff confirmed that the home has a programme of inhouse infection control training for all staff. Summerhouse DS0000063530.V330069.R01.S.doc Version 5.2 Page 22 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): 32, 33, 34 and 35 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home are deployed in sufficient numbers and have the necessary skills and experience to meet the needs of the people who live there. However, at the time of the inspection the home fell short of the minimum standard of 50 qualified at NVQ level 2 or above. The home operates a robust staff recruitment procedure, which ensures service users are protected. The staff training and development programme ensures the residents’ needs are met in line with the aims of the home. EVIDENCE: Staffing levels The home currently employs sixteen care support staff. Staff rosters showed and the manager confirmed that two care support workers are deployed during the day and the evening, with the manager and a housekeeper working additionally during the day. There is one care support worker who sleeps in on call overnight. Summerhouse DS0000063530.V330069.R01.S.doc Version 5.2 Page 23 These staffing levels are considered sufficient for the current needs and numbers of residents in the home. The manager and care staff confirmed that all staff work well as a team and readily cover for each other during holidays, sickness etc. Additional staff are available to support residents with special commitments. Both visiting professionals consulted felt there were always sufficient staff on duty at times when they visited the home. Staff recruitment It was clear from records that Summerhouse benefits from a very stable staff group. The manager confirmed that only two new care support workers had been recruited since this standard was last assessed. Individual staff recruitment files were available for inspection and showed that the home’s recruitment procedure includes an application form, terms and conditions of employment, medical and health information, proof of identification, two written references and police and Protection of Vulnerable Adults (POVA) checks on all staff. The inspector looked at the records of the two most recently recruited staff and found them to be in order. Staff training, development and competencies At the last inspection three requirements were made where shortfalls were identified in specific staff competencies. At this inspection there was clear evidence that the requirements had been met. The inspector looked at a staff training plan, which gives details of a full programme of mandatory training, completed and scheduled, including: Fire safety Basic food hygiene First aid Adult protection Infection control Health and safety Medication The manager confirmed that since the last inspection the home has put all staff, including long-standing staff, through a programme of induction, in line with the Common Induction Standards recommended by ‘Skills for Care’. The inspector saw evidence of the induction training by way of dip sampling. She also explained that she was about to set up individual staff training profiles, the format of which was available for inspection. Summerhouse DS0000063530.V330069.R01.S.doc Version 5.2 Page 24 The manager said that four care support workers have achieved the NVQ at level 2; one has achieved level 4 and two are currently undertaking the course at level 3. Others will be enrolled on courses during the year to ensure that the standard of 50 ratio of qualified staff is achieved. Summerhouse DS0000063530.V330069.R01.S.doc Version 5.2 Page 25 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, 39 and 42 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home, which is well run by a fully qualified and experienced registered manager. To ensure the home is run in the best interests of the residents the home has effective quality assurance systems for measuring its performance based on seeking the views of residents, representatives and stakeholders. The home’s policies, procedures and staff training ensure as far as is reasonably practicable, the health and safety of the residents and staff. EVIDENCE: Management – The manager has worked at Summerhouse for over eleven years and was appointed manager in June 2005. Since the last inspection she has completed Summerhouse DS0000063530.V330069.R01.S.doc Version 5.2 Page 26 the process for registration and has achieved all the management qualifications together with a diploma in mental health. Staff spoken with regarded the home as being well run. They confirmed that the manager was approachable and supportive, and staff morale was generally good. Quality assurance The proprietors have a development plan for the home, and the evidence of planned improvements to all aspects of the service demonstrates the home’s commitment to quality assurance. The home is relatively small and domestic in scale. In discussions with the manager she outlined the steps taken since the last inspection to monitor the quality of service at Summerhouse and produced documentary evidence: • • • • • • Annual care/support reviews involving residents, families, advocates and social services professionals. Six-monthly reviews of residents’ needs. Staff meetings and supervisions. Regular residents’ meetings. Monthly statutory visits to monitor the conduct of the home. Key worker system. The manager said that they had introduced formal satisfaction surveys for residents in the past, which had proved unsuccessful. Residents meetings and one-to-one sessions between residents and key-workers had proved a better way of gauging their satisfaction with the service. Health and safety All care support staff undertake mandatory training, which includes health and safety awareness, food hygiene and fire training. A sample of records was viewed, including fire logs, accidents, risk assessments and gas certificate, all of which were found to be in order. At the time of producing this report it has been confirmed by the manager that an electrical wiring certificate is in place. Summerhouse DS0000063530.V330069.R01.S.doc Version 5.2 Page 27 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 x 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 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 x 33 3 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 x 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Summerhouse DS0000063530.V330069.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? No 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 Requirement To ensure that an assessment has been undertaken of specific risks involved with the activities of a named individual. Timescale for action 23/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations The home should consider ways to make information in personal plans more person centred. Summerhouse DS0000063530.V330069.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Summerhouse DS0000063530.V330069.R01.S.doc Version 5.2 Page 30 - 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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