Inspection on 13/01/06 for Summerlands

This inspection was carried out on 13th January 2006.

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 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Summerlands 20/11/08

Summerlands 21/11/06

Summerlands 27/06/05

Summerlands 25/01/05

Summerlands 13/04/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Summerlands Westwell Leacon Ashford Road Charing Ashford Kent TN27 0EE Lead Inspector Mrs Ann Block Announced Inspection 13th January 2006 02:00 Summerlands DS0000023592.V264087.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 Summerlands DS0000023592.V264087.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. Summerlands DS0000023592.V264087.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Summerlands Address 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) Westwell Leacon Ashford Road Charing Ashford Kent TN27 0EE 01233 713454 Mr William Puxley Les Philip Edward Standley Care Home 9 Category(ies) of Learning disability (9), Mental disorder, registration, with number excluding learning disability or dementia (1) of places Summerlands DS0000023592.V264087.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 6 of the Service Users may also be Physically Disabled. Service users with Mental Health diagnosis to be restricted to one (1) whose DOB is 29/04/1969. 27th June 2005 Date of last inspection Brief Description of the Service: Summerlands is registered to provide 24 hour accommodation, personal care and support for up to 9 adults with learning disabilities. It is a modern detached property situated by a busy main road in a rural location on the outskirts of Ashford. Summerlands is set in 4 acres of well-maintained grounds incorporating a large lake which, with prior agreement, may be used by the public. Service users have unrestricted use of a secure lawned area with large patio, and assisted use of the lake area. To the front of the property is a large tarmac area for parking. There is a small detached day unit with snoozelem sited close to the main house. Service users accommodation is on two levels. The ground floor consists of four en suite bedrooms that are wheelchair accessible, a large lounge, dining room, kitchen, laundry and sunroom. There is access to the patio area and garden from the lounge. To the first floor there are three bedrooms and the managers office. Access to the first floor is by stairs, Summerlands does not have a lift. Summerlands DS0000023592.V264087.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission was represented by Ann Block, regulatory inspector, who was in the home from 13.55 to 20.45 pm. During that time some staff on duty, the manager and service users spoke with the inspector. The inspector is familiar with the service, judgments for this report have been made from conversation with staff, observation and general chats with service users, records and previous experience of the service where relevant. Les Standley has been in a manager’s role at the home for 2 years, he also holds an Area Manager post. Written and verbal feedback was provided to him during and at the end of the inspection. At the time of inspection there were 8 service users resident, all male. Interaction between staff and service users seen during the inspection was good. Staff were aware of potential risk and took gentle, non confrontational action. The manager and staff were responsive to suggestions made as part of the inspection. Comments received as part of the inspection included: ‘I like S (member of staff), she’s nice, she looks after me’ ‘Summerlands has made huge improvements since the 1990’s. Well done!’ ‘The staff are always very helpful about bringing our son to the main line station on his weekend visits to us.’ ‘The staff are very polite to me.’ ‘If anything happens at the home I think staff would contact me, I know they look after my son.’ ‘Fully satisfied with the care x is getting’ What the service does well: Service users are a group of people with learning difficulties who can display episodes of behaviour which challenges. Whilst it will always be difficult to meet individual needs in a group setting, the admission process and subsequent care offer a good standard of life for the group. Health care and medication is particularly well managed with health care regularly reviewed and responsive. Staff made a decision to work with this client group, the core Summerlands DS0000023592.V264087.R01.S.doc Version 5.0 Page 6 staff team show good rapport with service users and are clearly liked. Service users live in a safe, modern and homely environment where they have their own good sized and personalised rooms. They have opportunities to attend day activities and to have a holiday. They can keep contact with families and are supported to do so by staff. If they are not happy with the service they have staff who can communicate with them and make sure that their concerns are addressed. What has improved since the last inspection? 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. Summerlands DS0000023592.V264087.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 Summerlands DS0000023592.V264087.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): 1,2,3,4 & 5 Good systems are in place for a judgment whether Summerlands is suitable for potential service users. EVIDENCE: A statement of purpose and service users guide is available and contains detail as required. The statement of purpose is available in printed format, the service users guide in print and widget (pictorial) formats. Rights and responsibilities, including services included in the fees, is detailed. A signed contract between the home and the service user was seen in a file. Care managers, on behalf of prospective service users, make initial contact via the organisational placement officer who will decide which of the Counticare services has vacancies and would be most suitable. Managers are reported to be involved from that point. The manager said that a service user recently transferred from another Counticare service from where he had been given 28 days notice, had been assessed, visited Summerlands and stayed for a meal. The service user had lived at Summerlands previously, this was one reason why it was felt he would settle there. The stay was still under review. Staff were concerned that a minority of staff felt they did not have the skills to care for the level of challenging behaviours presented. They were confident that they had the skills to care for the remaining service user group. Summerlands DS0000023592.V264087.R01.S.doc Version 5.0 Page 9 Summerlands does not accept respite or emergency admissions due to the impact such stays may have on an already vulnerable group of people. One prospective service user has been admitted for a trial period. As he wasn’t compatible with the current group and his need couldn’t be met at Summerlands the placement was terminated. Summerlands DS0000023592.V264087.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 & 10 Service users preferences and needs are identified and well documented, more responsive recording of activities of daily living would enhance this. EVIDENCE: Each service user has a plan of care. One care plan was inspected in depth as part of case tracking. The service users keyworker holds overall responsibility for setting up the care plan, taking part in case reviews and being link between the service user, professionals and family. Overall, the plans were structured to give staff good information to provide consistent person centred care. Guidelines to deal with specific behaviours and health matters are now included. Daily records are made on a summary sheet. The records seen were very basic, did not link to any long or short term goals and did not evaluate the service users response to their day. If the service users quality of life were judged solely from records, there would be insufficient evidence that the service user was gaining value for money. Staff were able to explain in better detail how service users had a good quality of life, work towards agreed goals, had their choices met and were supported to maintain independence. Summerlands DS0000023592.V264087.R01.S.doc Version 5.0 Page 11 Service users consider they can make decisions about their lives. Staff on duty supported this process within the understanding and experience of the service user concerned. Rather than formal meetings, which the manager felt were ineffective given the needs of the service user group, views were obtained through one to one sessions and recorded. Service users assist in finance management as far as they are able. Taking risk is recognised as a human right. Many service users are unable to make informed judgments about risks for themselves. Risk management is decided by staff, care management, professionals and families as appropriate in the service users best interests. Risk assessments are now more routinely carried out, both for the individual and environmentally, and in response to incidents and accidents. Risk assessments are easily accessible by staff. Staff spoken to were aware of risks presented by individuals and whether to warn visitors to the home of potential risks. Staff have a good understanding of confidentiality. Service users were able to talk with the inspector in private. Records are held securely. Use of the communication book maintains confidentiality. Summerlands DS0000023592.V264087.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 & 17 Service users have a lifestyle with opportunities for social and recreational activities but would be better evidenced by recording how individual preferences have been offered, interpreted and met. EVIDENCE: Opportunities that arise during the day to develop personal skills are encouraged. Service users can help with cooking and cleaning their rooms. Some service users attend the Counticare day service in Folkestone. A small group had been swimming at Mote Park that morning. Staff are trying to reintroduce more external activities. There is a small day unit at Summerlands which has a snoozelem. Evening activities include trips to local pubs and to the Counticare disco. Transport is based at Summerlands with a member of staff normally allocated daytime driving. Other staff who have been assessed as competent drive as required. Staff rosters may be altered to meet social and recreational needs. Service users have holidays which they can help choose, some go on holiday with family. Recent holidays included Euro Disney and Butlins. Public use of the lake for fishing funds an amenity account which Summerlands DS0000023592.V264087.R01.S.doc Version 5.0 Page 13 can be used for outings such as to France for the day and to Chessington Theme Park. Service users are able to choose whether to engage in an activity. Daily records did not evidence that service users had a full day and whether their choices were informed, such as to join in a group activity, on a one to one, or to relax independently. Many references were made to contact with family, some service users make regular visits home with a number having gone home for Christmas. Visitors are welcomed to the home at all reasonable times. Staff respect service users rooms as private with locks which can be used by service users as appropriate. A number of service users have a distinct preference for spending time in their rooms watching TV or just relaxing. Bathrooms and toilets are lockable. The majority of service users have their finances managed through Counticare with monies individually named held in a combined dedicated account. Regular statements of transactions on individual parts of this combined account are provided to the home for monitoring. Records are made for monies held in personal wallets and individual tins, receipts are linked to expenditure. Staff countersign monies taken out such as when service users go to the pub. The manager said that records would be audited as part of Regulation 26 visits. As with other Counticare services, due to the system for requesting monies for service users, a delay of two or three days can occur, petty cash is used to top up any short term deficits. Support workers carry out all catering on the premises. The main meal is normally in the evening but can be altered as necessary. Packed lunches are made for those going out for the day, those attending the Counticare day service have a main meal there. If a service user chooses to buy a meal out rather than take a packed lunch, the meal is payable by the service user unless part of his care plan. A four-week rotating menu is used as a basis. Staff said this would be altered according to need. On the day of inspection the meal was tuna and pasta with a variety of yoghurts and fresh fruit for dessert. Special dietary needs are met with sugar reduced foods purchased for one service user. Local shops are used for general shopping. A service user had been shopping that morning and said he liked to push the trolley and help unload purchases. Summerlands DS0000023592.V264087.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 & 20 Service users individual preferences and health are competently promoted. EVIDENCE: Service users care plans give good detail of personal care needs and how this should be offered. Many care plans have a well written summary sheet detailing the preferred daily routines which can be used by bank or agency staff. Staff recognise that peoples individuality should be recognised, also that to meet needs may reduce anxiety for the service user and possible challenging behaviours. Service users choices of daily routines are flexible with encouragement offered where agreed day activities have been arranged, but never coercing a service user in a manner which might cause anxiety. Both male and female staff are employed. Where possible same gender care is provided. Where difficulties are anticipated, such as targeting a member of the opposite sex, guidelines and risk assessment are in place. A current situation is causing concern for some staff and this is being carefully monitored. Service users health and wellbeing is well maintained. The service liaises closely with other health professionals, including specialists in fields such as diabetes and epilepsy. Where necessary referrals are requested through the GP. Guidelines and routines testing as advised by such specialists are followed. Health care appointments and outcomes are recorded in separate Summerlands DS0000023592.V264087.R01.S.doc Version 5.0 Page 15 sections in the service users care plan which aids tracking of health care. From such records and associated notes, staff and professionals can identify whether further action is needed. Service users are supported to take part in managing their own medical matters, staff are aware that whilst some service users might wish to take greater responsibility, the outcomes would not be in their best interests. Records seen included detail of visits to dental, optical, chiropody and audiology services. A member of staff is responsible for medication management. The member of staff said that only staff who had training in safe handling of medication would be permitted to administer medication. Medication storage was secure and well ordered. The majority of medication is stored in a monitored dosage system. Records were completed accurately, including receipt and returns of medication. Systems are in place when medication is taken off the premises such as for day care or home visits. The GP has recorded agreement to the administration of homely remedies as listed and as required. Where invasive medication management is needed, external health professionals train staff in its use and accurate records are held. Summerlands DS0000023592.V264087.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Service users rights to be protected from the risk of abuse and to receive a good service are promoted. EVIDENCE: Complaint procedures were seen in the service users guide and on display in the hall and office, each giving relevant contact details. Copies are available in widget format. Systems are in place to ensure staff who are familiar with the service user’s preferred form of communication ensure concerns about the service or others are recognised and dealt with properly. Records of complaints are held which detail the nature of the complaint, action taken and outcomes, all in a manner which maintains confidentiality. Staff are trained in recognising and taking action where there is potential for abuse. There is access to the revised Kent and Medway adult protection joint working protocol which is used to protect service users. Many of the service user group may present behaviours which challenge given certain circumstances. Staff recognise that where this puts service users or others at risk, systems must be put in place to prevent further risk. Where necessary, adult protection meetings will be used to establish guidelines. Summerlands DS0000023592.V264087.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29 & 30 Service users enjoy an environment which suits them and is well maintained. EVIDENCE: Summerlands is a modern building, very light and airy with good sized rooms. At the time of inspection the home was clean and odour free. A housekeeper is employed for three hours a day. There is ample space to move around freely, both inside and outside. A large patio area is accessed from the lounge doors, a good size dining room gives easily cleanable space to eat. Views from the rear of the property over the lake are excellent. Fencing has been put up round an area of lawn at the rear as a safety precaution. A gated entrance leads to the car park. Counticare have their own maintenance staff who are currently in the middle of redecorating the lounge. A service users bedroom has been redecorated to his choice of colour, redecoration of the corridor will follow. The upper floor of the home has areas with sloping ceilings; in part of the landing area leading to two bedrooms and the bathroom, this significantly restricts height to under 6 foot and has been risk assessed for safe use. Service users have single rooms where they can display their own effects such as posters, models and have their own TV, DVD player etc. A service user has Summerlands DS0000023592.V264087.R01.S.doc Version 5.0 Page 18 been given a ground floor room, as he isn’t confident in using stairs. The four ground floor rooms are wheelchair accessible. A small group of service users transferred from an older property owned by Counticare and had been given first choice of bedrooms. Four bedrooms are en-suite. The upper floor rooms have use of a shower room with toilet and bathroom with toilet. Not all bedrooms have self contained hand washing facilities, which presents a risk of cross infection. The manager spoke of plans to change use of his first floor office to an additional bathroom. A toilet on the ground floor is for use by staff and visitors and is occasionally used by service users. Aids and equipment as required are provided. Kent Association for the Blind carried out an assessment of the premises for one service user. There is separate laundry area which has dual access from the ground floor hallway and the general office adjacent to the kitchen. Service users may assist in the laundry with staff support. There is a commercial washer and a drier in the laundry with a domestic washing machine in the adjacent room. Disposable hand drying towels and pump soap dispensers reduce the risks of cross infection. Summerlands DS0000023592.V264087.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 & 36 Service users are supported by properly trained staff who they know and like. Service users safety would be better evidenced by a through recruitment and training system. EVIDENCE: Job descriptions for staff were seen which reflected the work they were required to do. Staff spoken to understood their roles and responsibilities. The staffing structure allows for a deputy and team leaders. Staff refer for advice and support within the management structure. A supervision structure is in place. Supervision formats cover a range of work related issues including training needs. A staff roster is held which records planned and actual hours. There is normally one waking and one sleep in person on duty at night. The manager assured the inspector that there would only be two sleep in staff when service user numbers were reduced such as at Christmas. Staff felt that usually there were sufficient staff to meet the needs of service users. There were some concerns about staff skills in meeting the needs of the most recently admitted service user. A record indicated inappropriate action having been taken by a member of staff as she didnt know how to handle the situation. The manager said that additional hours were provided for this service user. Summerlands DS0000023592.V264087.R01.S.doc Version 5.0 Page 20 A core group of staff have worked at the home for some time. There is general movement within Counticare services as part of widening horizons and promotion. Due to transfers and other reasons, some new staff have been employed. Recruitment records for two recently recruited staff were assessed. Overall the systems used were sound with records obtained as required. Detail on the application form was not evidenced as being thoroughly checked as employment history hadn’t been properly validated, the appropriateness of references provided hadn’t been fully questioned and contradictory information not picked up. All staff are employed for a probationary period with a review held and the probationary period extended or employment terminated if necessary. Criminal records bureau and POVA (protection of vulnerable adults) checks are made. Criminal records bureau checks on the two most recently recruited staff had been requested but not returned at the time of inspection. One person was working as waking night person to ensure there was adequate night cover, following a period working with more experienced staff. Staff felt the core staff team was good with good team working and the wellbeing of residents foremost. They considered communication was sound. Many staff understand and use Makaton and learn additional personal signing used by service users. Regular staff meetings are held with minutes taken. Staff have access to a range of training with a training matrix available. Counticare have their own training coordinator who it was said ensured all staff have core and client specific training. The training matrix did not evidence that all staff hold current adequate training in all necessary areas. It was identified that the record had not been completed properly. Staff spoke of far more training than was recorded and more recently obtained. Whilst certificates are displayed on an office wall and some copied in personnel files, the current system is unsatisfactory to evidence that staff have the necessary skills to work at the home The majority of staff handle food, not all hold current food hygiene awareness training, those who do not have been put forward for the next training in February. A record of induction was seen. On completion of a satisfactory probation period, staff will undertake the Skills for Care induction procedure. Summerlands DS0000023592.V264087.R01.S.doc Version 5.0 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42 & 43 Service users benefit from a safe and well run home. EVIDENCE: The manager has been in a managerial role at Summerlands for nearly two years, and was manager of a sister home for some months previously. He has many years experience in working with adults with learning disabilities, including in a management role. He holds relevant qualifications in management and care. The manager felt he was able to implement policies and procedures which were relevant to Summerlands. Staff are required to sign they have read and understood policies as part of their induction and to any changes or new policies implemented. As the manager holds a post as Area Manager, responsibilities lie also within the senior team, including the Deputy. From evidence from previous inspection reports, responses to this inspection and from staff at Summerlands, service users benefit from an improved atmosphere and Summerlands DS0000023592.V264087.R01.S.doc Version 5.0 Page 22 enhanced environment. Staff are expected to work actively with service users and involve them as much as possible in the daily life of the home. Quality assurance is carried out. Counticare provides questionnaires to families, these questionnaires refer mainly to the quality of the organisation. A representative of Counticare carries out Regulation 26 visits to monitor the standard of service provision, copies of the report are sent to the Commission. Records as required by regulation and good practice are held. Records are stored securely with those seen containing detail as required by regulation. Records are, with minor exceptions, well maintained. There is a good awareness of the Data Protection Act and maintaining confidentiality. Accident and incident records are held, properly recorded and notified to other agencies as necessary. Systems are in place to ensure service users safety is maintained including servicing of fire safety equipment. A member of staff has responsibility for routine testing of equipment and is to ensure that regular weekly tests are carried out and recorded. Fire drills, which include service users, are held. All staff have had recent fire training and all but the most recently employed have attended a recent fire drill. Food was stored properly with fridge and freezer temperatures checked daily. One fridge which had been running at high temperatures has recently been replaced. Information provided by the manager as part of the inspection recorded up to date servicing of supplies and equipment. Hot water outlets are fitted with safety devices. Environmental risk assessments have been carried out including use of the lake and access to the lake by the public. There is security lighting around the outside of the home. Counticare has invested money in the service and is responsive to planning and development requests. A current certificate of employer’s liability was seen. Summerlands DS0000023592.V264087.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 2 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 1 1 1 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Summerlands Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 3 DS0000023592.V264087.R01.S.doc Version 5.0 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA33YA35 Regulation 18 (c) Requirement Staff must have the skills and knowledge to support service users needs at all times. This will include proper training to work with behaviour which challenges, training to safeguard themselves and others and client specific training. Any person working or having regular contact with service users must follow a sound recruitment procedure, this will include: • Timescale for action 31/03/06 2 YA34 19 (1) & (4) 31/03/06 3 YA35 18 (c) Evidence that all employees have a validated employment history, including the reason for leaving any previous work with vulnerable people • Checking the accuracy of statements made as part of an application • Checking the appropriateness of references provided. There must be suitable evidence 31/03/06 that all staff have the training appropriate for the work they are DS0000023592.V264087.R01.S.doc Version 5.0 Page 25 Summerlands to perform. The current system and its maintenance does not adequately provide this evidence. 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 YA6 2 Refer to Standard Good Practice Recommendations Daily records should be more comprehensive, recognising they are the evidence that the service is meeting the service users and funders expectations, link to long or short term goals and evaluate the service users response to their day. Records should evidence how preferences regarding an individual’s day have been offered, interpreted and met. YA12 Summerlands DS0000023592.V264087.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Summerlands DS0000023592.V264087.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!