CARE HOME ADULTS 18-65 Summerhouse Guyers Road Freshwater Isle of Wight PO40 9QA
Lead Inspector Janet Ktomi Unannounced 9th June 2005 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 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 Stationary 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 Version 1.10 Page 3 SERVICE INFORMATION
Name of service Summerhouse Address Guyers Road, Freshwater, Isle of Wight, PO40 9QA Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01983 755184 Make All Ltd Care Home 11 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (MD)(11), Mental disorder, excluding of places learning disability or dementia, over 65 years of age (MD/E) (4) Summerhouse Version 1.10 Page 4 SERVICE INFORMATION
Conditions of registration: none Date of last inspection None 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 who 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. The home aims to promote independence for the service users and has 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 had an acting manager. Summerhouse Version 1.10 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was the first unannounced inspection of this inspection year, core and additional standards were assessed. Core standards not assessed during this inspection will be assessed during the second unannounced inspection. The inspection was undertaken on a weekday daytime and lasted five hours during which a full tour of the building was undertaken. Discussions were held with staff on duty and everyone living at the home was met during the inspection and those who wished to gave the inspector their views about the service. All the service users stated that they enjoyed living at the home and liked the staff and new proprietor. Care and other records and documentation identified in the report were viewed. This unannounced inspection was undertaken two months after the home had been purchased by a new proprietor. Discussions were held with the proprietor and acting manager following the inspection to clarify the management arrangements. The registered manager had left the home unexpectedly during the week of the unannounced inspection. These discussions also clarified the action the proprietor intended to take in respect of some issues identified during the inspection and where appropriate have been included in the report. What the service does well: What has improved since the last inspection?
The home is currently undergoing a process of refurbishment and redecoration with service users being involved in decisions about furniture and colour schemes. Summerhouse Version 1.10 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Summerhouse Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Summerhouse Version 1.10 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 standard(s) 2, 3 and 4. The proprietor and acting manager are aware of the procedures that should be followed should a new service user be admitted to the home. EVIDENCE: The statement of purpose and service users’ guide is currently being revised by the new proprietor and will be assessed during the next inspection. The home currently has one vacancy within a shared bedroom. Discussions with the acting manager and proprietor following the unannounced inspection indicated that they were aware of the procedures that should occur prior to an admission to the home. The proprietor has obtained a blank copy of the preadmission assessment used within a similar home and intends to amend parts and use this along with care manager assessment information to determine if a person is appropriate to be admitted to the home. The proprietor and acting manager were clear that prospective service users would be invited to visit the home on several occasions, possibly involving overnight or weekend stays prior to their admission to the home. There have been no new admissions to the home for approximately one year and these standards will be re-assessed if any new people have been admitted at the time of the next inspection. Summerhouse Version 1.10 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 standard(s) 6, 7 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 care plans and risk assessments. The new proprietor and acting manager intend to include this in the revised design of care plans. 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 re-assessment 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, although it is the inspector’s opinion that more detail needs to be included within the care plans. Care plans were seen to be reviewed, where possible with the service users, every six months. Discussions with the new proprietor and acting manager following the inspection indicated that they intended to revise the care planning process to provide greater depth and information within care plans.
Summerhouse Version 1.10 Page 10 It would appear that service users do not at present each have a named key worker 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. Service users informed the inspector 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 colour schemes for the redecoration of their bedrooms, menus and communal areas. Significant individual risks were seen to be included within the care plans along with management arrangements. The risk assessment process needs to be reviewed and more information included within the assessment and management plans of the risks service users may present to themselves and others. 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. Discussions with the acting manager and proprietor following the inspection indicated that this is something that they intend to undertake as part of the care planning process. Care plans contained information about the support service users require in respect of their personal finances. These arrangements vary between service users dependant on their needs. Service users’ financial records will be assessed during the next inspection. Summerhouse Version 1.10 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 standard(s) 11, 12, 13, 14, 15, 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 the 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. Care staff were observed cleaning a service user’s room, and although he was not interested in assisting he was present and did carry some items outside when asked to do so. Some people attend a local day
Summerhouse Version 1.10 Page 12 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. Paid employment is not currently a realistic option for the service users 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 independence 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 the home 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. Service users informed the inspector that they are registered to vote and some stated they had taken part in the recent elections whereas others stated they had not been interested in doing so. During the inspection it was clear that support is flexible to meet individual needs. The new proprietor has purchased a house car that all staff with appropriate driving licences are able to drive. During the unannounced inspection service users were seen coming and going from the home as they wished throughout the day. The house diary and care plans detail internal and external activities individual service users have been involved in. Service users informed the inspector of things they had done both individually and as small groups. It was evident that individual interests are encouraged and supported by the home. Service users informed the inspector that they are supported to visit family members and are able to have visitors to the home. Visits are recorded in care plans and the house diary/handover book. Service users stated that they are able to choose what time they get up or go to bed, with information in the house diary of those who need to get up for day services or appointments on particular days. During the unannounced inspection service users were observed being offered options as to when and where they wanted to have drinks and meals, with one service user not wanting to have his lunch when it was ready and this was plated and put aside for later when he did want it. 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. Summerhouse Version 1.10 Page 13 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 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. People confirmed that they are fully involved in the planning of the home’s menus. Meals are taken either in the 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 afternoon and when they requested one. Care staff undertake the main cooking tasks and stated that they have undertaken food hygiene training. The diary stated that service users are frequently involved in making cakes, this was confirmed by service users who clearly enjoyed this activity. Summerhouse Version 1.10 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 standard(s) 18, 19 and 20. The home works with external professionals and meets the mental and physical health needs of service users. The home must ensure that Medication Administration Records are fully recorded and that discontinued medication is clearly recorded and removed from the following month’s MAR sheet. 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. The home has a small mobile bath hoist seen in the downstairs bathroom which could be used for service users who are less mobile due to age, and may have problems getting into the bath. The new proprietor intends to have a shower unit added to the downstairs bathroom that will provide a choice for service users between a bath or a shower and enable service users to maintain maximum independence in personal care. 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. The house diary was seen to contain information as to times people needed to get up for appointments or day services on different days of the week. 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
Summerhouse Version 1.10 Page 15 and are able to demonstrate their individual tastes. One service user was noted to be organising with a member of care staff to go to Newport to buy some new clothes with a store voucher she had received for her birthday. Service users have limited personal allowances and staff support them to budget for essential items such as clothing and shoes. Care plans detail how support, if required, will be provided. Help in making contact with specialists can be provided by the proprietor 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. Service users confirmed that they can see health professionals on their own however they generally prefer a member of staff to accompany them. 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 service 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 in the weeks prior to the unannounced inspection. His description of the care he had received would indicate that his physical health needs were being fully met. The home has a policy and procedure for the storage and administration of medications. The home uses the Boots MDS system for the administration of medications. All medications are stored in locked cupboards within a locked room used as an office and sleep-in room. 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 corresponded to the policy procedure. 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. A topical medication was still listed on MAR sheets however this had not been dispensed for a period of time, care staff stated that this had been stopped but this was not clear on the records. This should be reviewed by the GP and if no longer required should be removed from the MAR sheet. Summerhouse Version 1.10 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 standard(s) 22 and 23 The home has a complaints policy with service users’ opinions sought and respected by staff. Staff within the home are aware of adult protection issues and follow the locally agreed procedure in the event of adult protection concerns. EVIDENCE: People living at the home were aware of who to talk to if they had a complaint, however they did not have any concerns to discuss with the inspector. Staff explained that people mention concerns as they arise and these are dealt with immediately in order to alleviate anxiety. All worries are taken seriously even if they appear to be of a minor nature. Throughout the inspection people were seen talking with staff about a variety of issues and topics. Most of the people living at the home attend a local day centre and would also be able to discuss concerns with staff there if they wished. The home’s complaints policy was viewed during the inspection and would ensure that all complaints are resolved or forwarded to an independent authority such as care manager or the Commission. Information is available for people living at the home to contact the Commission if they wished. Staff spoken with were aware of actions to take if anyone had a complaint which they could not themselves immediately resolve. The complaints record was viewed, no complaints had been received since before the previous inspection. The home has an adult protection, whistle blowing, gifts to staff, and unexplained absence policy. The home has a copy of the Isle of Wight adult protection policy, with staff aware of the correct procedure to follow should an incident of abuse be suspected or reported.
Summerhouse Version 1.10 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 standard(s) 24, 25, 26, 27, 28 and 30. The new proprietor has commenced a planned programme of redecoration and refurbishment that will rectify the current poor environment of the home. EVIDENCE: The new proprietor has commenced a planned programme of redecoration and modernisation of the home. This will be undertaken on a priority basis over the next six months. This should address all the issues concerning the home’s environment and therefore no requirements are made. The home’s environment will be fully assessed again at the next inspection. During the week prior to the unannounced inspection there had been a significant water leak in the upstairs bathroom resulting in parts of the downstairs hall ceiling outside the downstairs bathroom being damaged. The Commission was notified about this event prior to the inspection. The proprietor stated that a builder/plumber had been consulted who had confirmed that the area was safe and that work was planned to repair the damaged ceiling. The downstairs bathroom was viewed during the inspection. This appears tired and shabby and needs the floor covering replacing as it is
Summerhouse Version 1.10 Page 18 damaged. The wall grab rail and soap holder must also be replaced as they appeared rusty. Prior to the inspection the proprietor had discussed with the inspector the downstairs bathroom and she intends to re-arrange the bathroom to provide a shower cubicle as well as replacing the dated bath and damaged floor covering. No requirements are made in respect of the downstairs bathroom but it will be re-assessed during the next inspection. The previous inspection required the stair carpet to be replaced as it was worn in places. This was done by the previous proprietors, however the carpet has already been damaged on one tread and this must be repaired. The inspector was shown the carpet samples that the new proprietor intends to use to replace the hall and stairs carpet. Service users are to be involved in the choices about colours and also the general redecoration of their bedrooms and communal areas. Service users confirmed to the inspector that they had been involved in colour discussions. The home has a lounge, dining room/second lounge and a large kitchen with table and chairs. Service users are able to use all these spaces and were seen doing so freely during the inspection. The home has a back and front garden that service users may access as and when they want to. Service users are able to use their bedrooms if they wish to be on their own or the second lounge/dining room when meals are not being served. Service users may smoke in the lounge or the gardens. The health risks of smoking are known by the service users, however for many it is both an addiction and an obsession, therefore a total no smoking ban would not be acceptable to the current service user group. Service users were aware that they were unable to smoke in the kitchen, dining room or their bedrooms. The lounge chairs are now very worn with the fabric damaged in places. The home is required to replace damaged communal furniture. The proprietor confirmed that she intends to do this as part of the refurbishment plans for the communal areas. 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. The inspector was able to talk with both of the people who currently share a bedroom and they confirmed that they were happy with the arrangement and get on with each other. None of the bedrooms have en-suite facilities but bathrooms are located close by. All bedrooms have a wash basin. 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 are also included in the refurbishment plans of the new proprietor. One bedroom has already been redecorated and another was under way during the inspection. One service user showed the inspector the new bedroom furniture she had been provided with and was clearly very happy with her room and pleased with the changes the new proprietor had achieved. The bedroom doors are all lockable but many of the service users choose not to lock their rooms. Service users confirmed
Summerhouse Version 1.10 Page 19 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. 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. Care staff confirmed that it is not used when the kitchen is in use and that laundry is transported to the washing machine in a plastic basket with a lid. None of the people living at the home is generally incontinent and therefore the lack of a sluicing facility is not a problem. Summerhouse Version 1.10 Page 20 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33 and 34. The home has an effective staff team provided in appropriate numbers to meet the needs of the service users. The home must ensure that all information pertaining to staff is available at inspections. EVIDENCE: The inspector was able to meet staff from the morning and afternoon shifts including a new member of staff who was working a trial shift prior to commencing work at the home. Most of the staff have been employed at the home for a considerable period of time and have a good knowledge of the service users. Two staff are provided for the morning and afternoon shifts with one sleep-in staff overnight. In addition a domestic, the acting manager and proprietor are also available. At present care staff undertake all the cooking in the home and the new proprietor hopes to recruit a cook to replace the domestic. This will then enable care staff to spend more time with service users and encourage them to be more involved in domestic activities and keeping their rooms clean as well as providing opportunities for external activities. The home does not use agency staff and any uncovered shifts are done by members of the existing care staff. This was observed during the unannounced inspection when the sleep-in staff member telephoned in sick and the acting manager organised with an evening staff member to cover the sleep-in shift. When required specialist advice is sought from the community
Summerhouse Version 1.10 Page 21 mental health team or other relevant health professionals. One member of the care staff is undertaking NVQ level 2 and there was a note in the home’s diary in respect of the external verifier visiting the home. Four other care staff already have NVQ level 2 in care. There are regular staff meetings at the home, with one having been held the day prior to the unannounced inspection. During the unannounced inspection a new member of care staff was working a trial shift in the home. The inspector was unable to view all the recruitment information in relation to this person as the proprietor, who was not present in the home, had taken the file home. All information specified in the regulations and Schedule 2 must be available for inspection. Summerhouse Version 1.10 Page 22 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 40, 41, 42, The proprietor has taken the necessary steps to compensate for the unexpected departure of the registered manager. EVIDENCE: On the day prior to the unannounced inspection the home’s registered manager unexpectedly resigned with immediate effect. The proprietor provided the Commission with a letter detailing the arrangements that she had put in place to provide management cover until a new manager could be registered with the Commission. The arrangements included increased contact with external professionals and on-call arrangements with a similar home to Summerhouse on the mainland whose manager would be available to provide advice and support to senior and care staff. Two senior care staff are already attending specific mental health training at the college and one is due to commence the Registered Manager’s Award. These measures would appear to be appropriate and the proprietor has kept the Commission fully aware of the management arrangements at the home. Summerhouse Version 1.10 Page 23 The home has appropriate policies and procedures, however there is a need to ensure that these are updated to reflect the changes in the home’s management structure following the departure of the registered manager. Staff have all signed the policies to confirm that they have read these. Policies are available to staff at all times and held within the sleep-in office. During the unannounced inspection a number of records were seen including staff rotas, diary, care plans, policies and procedures file, complaints book, accident book, fire equipment safety check record, Medication Administration Records and menus. All were found to be well maintained, up to date and contained the required information. 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 of the new staff member were not available at the time of the unannounced inspection. The home must ensure that all information within the schedules is available for inspection. Care staff have received initial and update training in fire awareness, first aid, health and safety, food hygiene and infection control, records for which were seen during the inspection. The home has policies and procedures to ensure the safety for service users and staff. With the exception of the damaged stair carpet there were no visible hazards noted within the home with records indicating that the fire detection equipment is checked weekly. Summerhouse Version 1.10 Page 24 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 3 3 x Standard No 22 23
ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 3 x 2 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 2 3 3 2 2 x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x 3 3 2 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 Score 3 3 2 Standard No 37 38 39 40 41 42 43 Score x x x 3 3 2 x
Page 25 Summerhouse Version 1.10 21 x Summerhouse Version 1.10 Page 26 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 9 Regulation 21 (1) Requirement The risk assessment process within the home must be revised and risk assessments and risk management plans must contain greater detail. The home must ensure that all medication administration records are fully maintained. Medication no longer required must be reviewed by the GP and removed from the MAR sheets. All information as specified in Schedule 2 must be available for inspection. Timescale for action 1-9-05 2. 20 13 (2) 1-7-05 3. 34 42 19 (b(i)) Schedule 2 1-8-05 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 6 Good Practice Recommendations Each service user should have a named key-worker, where appropriate selected by the service user. Summerhouse Version 1.10 Page 27 Commission for Social Care Inspection Mill Court Furrlongs Newport PO30 2AA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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