Inspection on 08/12/05 for Summerhouse

This inspection was carried out on 8th December 2005.

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 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 18 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 05/04/06

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 Janet Ktomi Unannounced Inspection 8th December 2005 10:00 Summerhouse DS0000063530.V270899.R01.S.doc Version 5.0 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.V270899.R01.S.doc Version 5.0 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.V270899.R01.S.doc Version 5.0 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.V270899.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th June 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 the 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 and at the time of the unannounced inspection did not have a registered manager. The manager will soon be applying to the Commission for registration. Summerhouse DS0000063530.V270899.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second unannounced inspection of this inspection year; core and additional standards were assessed. The inspection, carried out by two inspectors, was undertaken over two days and lasted in total six hours. The inspection took two days as the inspectors returned following the initial unannounced inspection to meet with the manager and proprietor who were not present on the first day of the inspection. A tour of the building was undertaken. Discussions were held with staff on duty and everyone living at the home who was in during the inspection. Service users stated that they enjoyed living at the home and liked the staff. Care and other records and documentation identified in the report were viewed. What the service does well: What has improved since the last inspection? Since becoming the proprietor of the home in April 2005 the proprietor has commenced a programme of refurbishment and redecoration. The downstairs bathroom has been completely refurbished and a shower provided in addition to the new bathroom suite. The upstairs WC has also been refurbished with all fixtures replaced. The front lounge, hall and stairs have been redecorated and new carpet laid in the hall/stairs. A number of bedrooms have been redecorated and new furniture provided. Service users have been involved in colour scheme choices. The proprietor has appointed a manager who is undertaking a mental health course at the Isle of Wight College and completing her NVQ level 4. The manager then intends to undertake the Registered Manager’s Award. The manager and proprietor are working to develop the home’s care planning and risk assessment procedures and develop improved record keeping procedures. Summerhouse DS0000063530.V270899.R01.S.doc Version 5.0 Page 6 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. Summerhouse DS0000063530.V270899.R01.S.doc Version 5.0 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.V270899.R01.S.doc Version 5.0 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): No standards assessed. EVIDENCE: Standards 2, 3 and 4 were assessed during the previous unannounced inspection. Discussions with the manager during this inspection indicated that she understood the home’s registration categories and was aware of the procedures she should take if she wanted to admit a new service user. At the time of the unannounced inspection the home had ten service users. There have been no new admissions to the home for approximately one year and these standards will be reassessed if any new people have been admitted at the time of the next inspection. Summerhouse DS0000063530.V270899.R01.S.doc Version 5.0 Page 9 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. All service users have individual care plans that reflect issues identified in assessments. Risk assessments are included within care plans. There is a need to provide more information within risk assessments to state how risks identified may be managed. EVIDENCE: All service users have individual care plans, a number of which were seen during the unannounced inspection. These included a pre-admission assessment, for more recent admissions, and a reassessment of need undertaken for people who had lived at the home for a longer period of time. Care plans stated identified needs and how these should be met. Care plans were seen to be reviewed, where possible with the service users, every six months. It would appear that service users do not at present each have a named keyworker and it is recommended that the home consider nominating a key worker for each service user, where possible service users should be involved in choosing their key workers. Summerhouse DS0000063530.V270899.R01.S.doc Version 5.0 Page 10 Service users informed the inspectors that they are able to make choices and decisions about what they do and where they spend their time. During the inspection service users were seen making choices about day-to-day activities and informed the inspector that they had been involved in the choices about menus, colour schemes for the redecoration of their bedrooms and communal areas. The home does have service users’ meetings, however a lot of decisions are made more informally as situations and choices arise. Individual risk assessments were seen to be included within the care plans. The new manager has reviewed the risk assessment process. The new risk assessments identify risks but do not contain adequate information as to how these risks will be managed. Where appropriate the risk assessments should be undertaken with the service user and any relevant external professionals such as Community Psychiatric Nurses or Care Managers. This could be combined with care plan reviews and CPA reviews. The home must provide more detailed management plans for identified risks. Care plans contained information about the support service users require in respect of their personal finances. These arrangements vary between service users depending on their needs. The arrangements to support service users with their personal finances were assessed and would appear appropriate. Discussions with the manager indicated that she would like some service users to have greater control of their personal finances and will explore options for this with the service users and their care managers. There is a need to remove the name of the previous proprietor/manager from the building society accounts held in the names of some of the service users. Summerhouse DS0000063530.V270899.R01.S.doc Version 5.0 Page 11 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): 11, 12, 13, 14, 16 and 17. Service users are encouraged to access external social and community activities and to engage in appropriate in-house activities. Service users enjoy a varied nutritious diet. EVIDENCE: Staff encourage people who live at the home to develop their independence skills and provide opportunities for involvement in cooking, cleaning and tidying activities within the home. Staff were observed offering support in a sensitive manner so as to promote independence and self-confidence. Service users spoken with during the inspection confirmed that they have opportunities to maintain and develop social, emotional and independent living skills. A number of the people who live at the home indicated that they were not keen to participate in domestic tasks and would leave these activities for care staff to complete. Another service user was happy to inform the inspectors that she kept her room clean and tidy. Some people attend a local day centre and they and others go out independently to the local village. Others have support to access the local community. Information about individual social activities was noted in care plans. Summerhouse DS0000063530.V270899.R01.S.doc Version 5.0 Page 12 Paid employment is not currently a realistic option for the people living at Summerhouse. Should a service user express a wish for employment or work experience then the home would involve their care manager in identifying an appropriate path to meet their goal. Service users are supported to maintain and develop independent skills by the care staff both within and external to the home. Most of the service users attend a local day centre where they are able to join a variety of activities. People living at Summerhouse are encouraged to develop and maintain interests outside of the home. The local community is supportive of the people living at the home and are helpful to them when they visit local shops etc. As many of the people have lived at the home for a number of years they are recognised within the community and acknowledged positively. People who live at the home use all the local facilities such as hairdressers, shops, pubs and health services. During the inspection it was clear that support is flexible to meet individual needs. Service users stated that they are able to choose what time they get up or go to bed. During the unannounced inspection service users were observed being offered options as to when and where they wanted to have drinks and meals. Service users were also seen telling staff where they were going when they went out; this was clearly part of their normal routine and would ensure that staff knew where people were in case they were delayed in getting back. Throughout the inspection service users and care staff were observed interacting appropriately with each other. At the time of the unannounced inspection there were no pets within the home. Previously one service user had a pet dog and the proprietor stated that any reasonable requests to keep a pet would be considered. Service users were fully aware of the house rules in relation to smoking and knew that they are only able to smoke in the back lounge or outside in the garden. Service users understood the need to comply with this rule and none had any concerns with this. The people who live at the home were all very complimentary of the food provided, stating that it was well cooked, with plenty of food available. The menus for the week were seen during the inspection along with menus for previous weeks, these indicated that a varied nutritious diet is available. Christmas day menu was also seen displayed on the kitchen notice board. People confirmed that they are fully involved in the planning of the home’s menus. Meals are taken either in the lounge/dining room or the kitchen and whilst main meals are at set times breakfast times are flexible and meals may be saved for people who are not at home when meals are served. People confirmed that hot and cold drinks are available throughout the day and during the inspection people were observed making themselves drinks as well as being provided with a hot drink in the middle of the morning and when they Summerhouse DS0000063530.V270899.R01.S.doc Version 5.0 Page 13 request one. Care staff undertake the main cooking tasks and stated that they have undertaken food hygiene training. Summerhouse DS0000063530.V270899.R01.S.doc Version 5.0 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 and 20. The home works with external professionals and meets the mental and physical health needs of service users. Medication is stored and administered appropriately, however the home must ensure that Medication Administration Records are fully recorded and that medication received into the home is logged in an appropriate format. EVIDENCE: Care plans seen indicated that service users are generally independent in personal care and are all fully mobile, but may require reminders and encouragement to attend to their personal care needs. One service user stated that if he needs help this is available from care staff. Since the last inspection the home has completely refurbished the downstairs bathroom and installed a new shower. Service users and staff confirmed that this is very popular and provides greater independence for service users. A shower stool is provided in the shower and this must be replaced as the seat has become damaged and may present an infection control risk as well as a danger to service users’ skin integrity. Service users confirmed that times for getting up/going to bed are flexible and unless they have an appointment they can get up when they want. Service users confirmed that breakfast was always available regardless of the time they got up. The inspector witnessed staff knocking on service users’ doors before entering. Service users choose and wear their own clothes and Summerhouse DS0000063530.V270899.R01.S.doc Version 5.0 Page 15 are able to demonstrate their individual tastes. Service users have limited personal allowances and staff support them to budget for essential items such as clothing and shoes. Help in making contact with specialists can be provided by the proprietor, manager or care staff but service users can choose to see visitors, or attend any appointments alone. The majority of care staff have worked at the home for a number of years and clearly have a good working relationship with the service users. Service users described care staff as helpful and nice. All service users are registered with the local GP practice and attend either on their own or with staff support when necessary. The health needs of service users are identified in care plans with any changes in needs or medication also recorded. Details of dentists, chiropody, opticians, blood tests and specialist appointments such as CPN and consultants are recorded in care plans. Service users attend day services in the village and these are also the local base for the Community Mental Health team. Service users therefore have good access to their Community Psychiatric Nurses and Care Managers on a regular basis as well as when professionals visit the home. One service user described to the inspector the care and support he had received when he had been physically ill and had to attend hospital in Southampton for investigations. His description of the care he had received would indicate that his physical health needs were being fully met and that he had been emotionally supported by the care staff through a difficult and anxious time. The home has a policy and procedure for the storage and administration of medications. The home uses the MDS system for the administration of medications. All medications are stored in a new locked metal medication cupboard. None of the people who live at the home self-administer medication. A record is maintained of all current medication for each person living at the home within the MAR sheet and care plans. Care staff on duty explained the administration procedure to the inspector. This would appear appropriate. The MAR sheets were examined and found to contain some gaps where staff had not signed to confirm that medication had been given or a code used to indicate that medication had not been given for a reason e.g., refused. The home does not record medication received into the home. This was discussed with the manager. The four weekly recording sheets would not be appropriate as medication is received weekly in pre-dispensed systems. The home must identify an appropriate recording method to ensure that all medication received into the home, and returned to the pharmacist is recorded. Should additional medications be prescribed by the GP during the four weekly recording sheets then a member of care staff adds this to the sheets. Care staff adding new prescriptions must ensure that they are fully completed including dosage, date, signed and preferably witnessed by another member of care staff. Some of the care staff have attended medications training provided by Boots. Newer staff have not done so and described to the inspector the in house training received. Whilst this should ensure that they are capable of correctly administering Summerhouse DS0000063530.V270899.R01.S.doc Version 5.0 Page 16 medication it would be considered good practice for all staff to attend training and information about training options was provided to the proprietor. Summerhouse DS0000063530.V270899.R01.S.doc Version 5.0 Page 17 Summerhouse DS0000063530.V270899.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No standards assessed. EVIDENCE: Standards 22 and 23 were assessed during the previous unannounced inspection in June 2005. At the time of this unannounced inspection service users spoken to by the inspectors had no concerns or complaints. Summerhouse DS0000063530.V270899.R01.S.doc Version 5.0 Page 19 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, 29 and 30. The new proprietor has commenced a planned programme of redecoration and refurbishment that has improved the home’s environment. Additional work is planned to further improve the home. EVIDENCE: Since becoming the proprietor of the home in April 2005 the proprietor has commenced a programme of refurbishment and redecoration. The downstairs bathroom has been completely refurbished and a shower provided in addition to the new bathroom suite. The upstairs WC has also been refurbished with all fixtures replaced. The front lounge, hall and stairs have been redecorated and new carpet laid in the hall/stairs. A number of bedrooms have been redecorated and new furniture provided. Service users have been involved in colour scheme choices. The front lounge has now been designated as lounge/dining room and smoking is no longer permitted in this room. The back communal room is now a lounge and smoking is permitted in this room and outside the home. Therefore a smoke free sitting room is now provided. Service users were aware of where they can smoke in the home and appeared happy with the arrangements. The proprietor outlined her plans to provide new furniture in the lounge/dining Summerhouse DS0000063530.V270899.R01.S.doc Version 5.0 Page 20 room and back lounge as furniture has become damaged and worn through normal usage. Some of the people living at the home showed the inspector their bedrooms. The home has seven single bedrooms and two rooms registered as shared rooms. Two people currently use one bedroom as a shared room. The inspector was able to talk with one of the people who currently share a bedroom and they confirmed that they were happy with the arrangement and get on with the person they share with. None of the bedrooms have en-suite facilities but bathrooms are located close by. All bedrooms have a washbasin. Although some of the single rooms do not meet the standards in terms of size there is enough compensatory space in other parts of the building that it does not cause difficulties for the current service user group who spend the majority of their time in communal areas. Bedrooms have also been included in the refurbishment plans of the new proprietor. Several bedrooms have already been redecorated. The bedroom doors are all lockable but many of the service users choose not to lock their rooms. Service users confirmed that they are encouraged to help with keeping their bedrooms clean and tidy, however staff accept that this is not a priority for some service users. Service users had personalised their bedrooms to display their own hobbies and interests. Within the shared room there is screening available around the washbasin to provide privacy when required. During the inspection a discussion was held with the proprietor about her plans to increase the size of the small staff sleep-in room and then use one of the current shared rooms as a single room. Additional office/sleeping room is being provided elsewhere in the home. This would result in the home only having one shared room. Once detailed plans have been prepared these should be submitted to the Commission and a decision made as to whether these are acceptable. The home has not yet covered the radiators. The proprietor explained the difficulties she has experienced in finding the correct size radiator covers. The provider must complete risk assessments for radiators and arrange to have those identified as high risk to be covered. As previously stated the downstairs bathroom has been completely refurbished and now contains a shower cubicle. The bathroom now looks pleasant and clean. The shower cubicle was seen to contain a shower stool that was damaged on the seat. This could present an infection risk and also a risk to service users’ skin integrity. This must be replaced. The upstairs WC has also been completely refurbished. The home has one additional bathroom which has yet to be refurbished. The home at the time of the unannounced inspection appeared clean and was free from offensive odours. The home has a policy on infection control and safe handling of spillages. Care staff confirmed that they had undertaken training in infection control. The laundry facility is in a small space between the kitchen and dining room. None of the people living at the home is generally incontinent Summerhouse DS0000063530.V270899.R01.S.doc Version 5.0 Page 21 and therefore the lack of a sluicing facility is not a problem. The home has side access and this was noted to contain a disused bed and some other items of rubbish. This must be removed. Summerhouse DS0000063530.V270899.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 The home provides appropriate numbers of staff to meet service users’ needs. The home must ensure a more thorough recruitment process is implemented and POVA checks undertaken prior to staff commencing employment. The home must improve the staff training records to enable assessment of training undertaken. EVIDENCE: The majority of staff have worked at the home for a number of years and clearly had a good understanding of the service users. Service users stated that they liked the care staff and this was apparent during interactions observed. Two staff are provided for the morning and afternoon with one sleep-in staff overnight. The manager generally works a daytime 9.00 – 5.00 shift but will cover other shifts as required. The home also employs a part time cleaner who works weekday mornings and is responsible for the bathrooms and communal areas, and a gardener. The home does not use agency staff and existing staff cover extra shifts as required. When required specialist advice is sought from the community mental health team. It was not possible to fully assess the home’s training programme, as the records were not up to date. The proprietor stated that two staff (one the manager) are undertaking NVQ level 4 and a mental health course at the Isle of Wight College. Three care staff have NVQ level 2 with an additional two staff commencing NVQ 3 in January 2006. Due to their experience these staff are Summerhouse DS0000063530.V270899.R01.S.doc Version 5.0 Page 23 going straight into level 3 NVQ. One of these care staff confirmed to the inspector that she is due to commence her NVQ in January. The proprietor stated that there is a procedure for induction of new care staff, however there was no documentation to confirm this. The home has some videos to provide training and must record when these are viewed by staff. The home must be able to demonstrate that care staff receive appropriate induction and ongoing training via training records. As previously stated it is required that care staff who administer medication have appropriate external training. Recruitment was discussed with the proprietor who takes the lead responsibility for this. The recruitment files for recently appointed care staff were seen. The majority of the required information was available within these, however there was no evidence of CRB and POVA Checks. The proprietor was unaware of the amended regulations of July 2004 and the availability of email POVA checks. The proprietor stated that she has experienced problems with the umbrella organisation and is now arranging for new CRBs to be undertaken on these care staff. The home must not commence new staff working at the home until a clear POVA check has been received. The proprietor must confirm to the Commission in writing when outstanding CRBs have been received. Also noted within the recruitment files was that care staff had commenced employment before two written references had been received. The proprietor thought that the manager had undertaken verbal references but there was no evidence that this had occurred. If verbal references are taken then a written record of these must be made, stating the date, who was spoken to and what was said about the applicant. These must be followed up with written references. Summerhouse DS0000063530.V270899.R01.S.doc Version 5.0 Page 24 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. The management arrangements are appropriate for the size of the home. Quality monitoring procedures should be considered and record keeping must be improved. Generally the home provides a safe place for staff, visitors and service users. EVIDENCE: The manager has now been managing the home for approximately five months during which time she has been attending the Isle of Wight College weekly for a mental health course and undertaking NVQ level 4 in care. The inspectors were able to talk with the manager and she confirmed that she felt both these courses were beneficial to her role. The manager has been supplied with registration application forms and should commence the registration process in the New Year. The inspectors confirmed that registration could commence prior to the qualifications being completed. Prior to becoming the manager, the manager had worked at the home for a number of years and knows the service users well. The proprietor has a high level of input into the home and it was Summerhouse DS0000063530.V270899.R01.S.doc Version 5.0 Page 25 apparent during the inspection that both the manager and proprietor are able to work together and respect each other’s skills and knowledge. The home has regular staff meetings that are often followed by a service user meeting. During the inspection service users confirmed that they have been involved in decisions about the home such as redecoration and refurbishment as well as day-to-day decisions about menus. The home does not have a specific quality assurance/quality monitoring system or route for obtaining service users’ views and opinions such as questionnaires or surveys. The proprietor stated that she would commence completing Regulation 26 reports from January 2006, as she now also owns another care home on the Island. The proprietor should consider how she would gather and record service users’ views as part of a quality monitoring system. From January 2006 the manager is to commence an audit, weekly and monthly, of various aspects of the home and record. This could be used as part of a quality audit tool. During the unannounced inspection a number of records were seen including staff rotas, care plans, risk assessments, medication administration records, recruitment records and menus. Records were appropriately stored within locked facilities with access available to people who require it. As previously stated the records in relation to the recruitment must be improved, with two written references and CRB/POVA checks undertaken. The home must ensure that all information within the schedules is available for inspection. The Medication Administration Records were incompletely recorded with gaps and no records as to medication received into the home or returned to the pharmacy. Training records must be available to confirm that care staff have undertaken appropriate induction and ongoing training to meet service users’ needs. Generally the home provides a safe place for staff, visitors and service users. As identified in this report the training records for care staff were not fully maintained and as such evidence that safe working practice in connection with food hygiene, infection control, moving and handling, fire awareness and first aid are not available. The inspectors were shown a folder in which the manager intends to record weekly and monthly checks undertaken on the home as well as documenting when external professionals undertake gas and electric checks. This folder, when in use, will resolve some of the record keeping issues identified and provide evidence that the home is a safe place. Summerhouse DS0000063530.V270899.R01.S.doc Version 5.0 Page 26 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 2 2 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 3 1 2 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Summerhouse Score 3 3 1 X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X 2 2 X DS0000063530.V270899.R01.S.doc Version 5.0 Page 27 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. 2. Standard YA9 YA41 YA20 YA41 Regulation 13 (3)(c) 13 (2) Requirement Risk assessments must state how risks will be managed. Medication administration sheets must be fully recorded. This was required at the previous unannounced inspection in June 2005. Further enforcement action may be considered should this requirement continue not to be met. All medication received into the home must be recorded. Medication returned to the pharmacy must be fully recorded. Additions/changes to the printed Medication Administration sheets must be fully completed, dated, signed and witnessed. All staff who administer medication must undertake appropriate external training. Radiators must be risk assessed and where high risk identified must be covered. The shower stool must be replaced. Rubbish and disused furniture by the side of the house must be DS0000063530.V270899.R01.S.doc Timescale for action 28/02/06 12/12/05 3. YA20 YA41 13 (2) 30/12/05 4. YA20 YA41 13 (2) 30/12/05 5. 6. 7. 8. YA20 YA24 YA27 YA30 13 (2) 23 (2)(p) 13 (2)(c) 13 (2)(o) 30/03/06 30/03/06 30/01/06 30/01/06 Summerhouse Version 5.0 Page 28 removed. 9. YA34 YA41 19 (4)(b) Staff must not commence working at the home until a CRB has been applied for and a POVA check returned. Verbal references must be fully documented and staff must not commence employment until at least two references have been undertaken. The home must be able to demonstrate that all care staff undertake appropriate induction and ongoing training. Records must be kept. 12/12/05 10. YA34 YA41 19 (1)(b) 12/12/05 11. YA35 YA41 18 (1)(a) 30/01/06 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 YA39 Good Practice Recommendations The home should consider introducing a key worker system. The manager and proprietor should consider how they would gather service users’ views and opinions as part of a quality monitoring system. Summerhouse DS0000063530.V270899.R01.S.doc Version 5.0 Page 29 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. 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