Inspection on 27/06/05 for Summerlands

This inspection was carried out on 27th June 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Summerlands 20/11/08

Summerlands 21/11/06

Summerlands 13/01/06

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 Ann Block Unannounced 27 June 2005 14:50 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. Sumerlands H56-H06 S23592 Summerlands V225908 270605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Summerlands Address Westwell Leacon Ashford Road Charing Ashford Kent TN27 0EE 01233 713454 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) Mr William Puxley Mr Les Standley CRH Care Home 9 Category(ies) of Learning disability (9) registration, with number Mental Disorder (1) of places Sumerlands H56-H06 S23592 Summerlands V225908 270605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. 6 of the Service Users may also be Physically Disabled. 2. Service users with Mental Health diagnosis to be restricted to one (1) whose DOB is 29/04/1969. Date of last inspection 25 January 2005 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 man 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 which are wheelchair accessible, a large lounge, dining room, kitchen, laundry and sunroom. There is access to the patio area from the lounge. To the first floor there are three bedrooms and the managers office. There is also a room which is currently being used as a sleep in room. Access to the first floor is by stairs, Summerlands does not have a lift. Sumerlands H56-H06 S23592 Summerlands V225908 270605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission was represented by Regulatory inspectors Ann Block and Gary Bartlett who were in the home from 2.50 to 7.10 pm. One service user chose to speak with an inspector in private, other service users and staff spoke in small groups. Evidence was also gained from observation of practice and the environment, records and previous inspection reports. At the time of inspection there were 7 service users resident, all male. Les Standley has been in a managerial role at the home for 18 months. He also oversees two other homes owned by Counticare. Interaction between staff and service users seen during the inspection was good. A service user said he liked the staff, although missed his keyworker who had recently left. Service users and staff particularly liked the location of Summerlands and the view from the rear over the lake and surrounding countryside. What the service does well: Service users and others have good information about Summerlands and can make trial visits there. Service users will have a contract between Counticare and themselves. Each service user has a care plan which they will be involved in setting up. Staff know that service users affairs should remain confidential. Service users are able to make decisions about their lives, including activities and holidays. They can talk about things at meetings and with keyworkers and know the people who they can complain to if necessary. Service users have a full programme of daily activities and have been on holidays away from the home. Service users told the inspector about recent holidays and how much they had enjoyed them. Staff are rostered to be available to help with activities and holidays. Service users are encouraged to keep contact with family and friends and some make regular home visits. Service users have privacy if they wish, being able to lock their own door and bathrooms and toilet doors. Service users can keep a small amount of money on the premises and have a safe system to hold larger amounts. Service users like the food, can help to prepare meals and said they can ask for something different if needed. They like to help with the main shopping. Service users like the house, they have a secure garden and patio and large grounds to use and have wonderful views. Each service user has a good sized bedroom which they can make their own. In addition, they have a large bright lounge and dining room. Four bedrooms are Sumerlands H56-H06 S23592 Summerlands V225908 270605 Stage 4.doc Version 1.30 Page 6 en suite and wheelchair accessible. Service users can do their own washing if they wish and have staff to help them. Service users like the staff, some who have worked with them for many years, and like having a keyworker. Staff have access to a good range of training, including some specific to the service user group. Service users know they are in good hands by having a qualified and experienced manager in post. The home is well maintained and safety of servicing and supplies is carried out. 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 Sumerlands H56-H06 S23592 Summerlands V225908 270605 Stage 4.doc Version 1.30 Page 7 contacting your local CSCI office. Sumerlands H56-H06 S23592 Summerlands V225908 270605 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Sumerlands H56-H06 S23592 Summerlands V225908 270605 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4 & 5 Good systems are in place for service users to make a judgment whether Summerlands is suitable for them. Expanded detail in the statement of purpose would enhance this process. EVIDENCE: A statement of purpose and service users guide is available and contains the majority of detail as required. To offer prospective service users better information about Summerlands, more detail of staff employed with their qualifications and training, plus mention of the use of the lake and surroundings by the public, must be included. The statement of purpose is available in printed format, the service users guide in print and widget. Rights and responsibilities, including services included in the fees, is detailed. 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 assessment process was not inspected, there having been no recent placements in Summerlands. Previous inspections have recorded that prospective service users are able to visit Summerlands, meet other service users and stay for a meal. All placements are subject to a trial period to further assess suitability. Sumerlands H56-H06 S23592 Summerlands V225908 270605 Stage 4.doc Version 1.30 Page 10 A signed contract between the home and the service user was seen in a file, the contract had those appendices attached which were referred to in the main body of the text. Summerlands does not accept respite or emergency admissions. Sumerlands H56-H06 S23592 Summerlands V225908 270605 Stage 4.doc Version 1.30 Page 11 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) 6,7,8,9 & 10 Service users preferences and needs are identified and well documented, more responsive recording would enhance this. EVIDENCE: Each service user has a plan of care. One care plan was inspected in depth as part of case tracking. Overall the plans were structured to give staff with good information to provide consistent person centred care. Including guidelines and information provided by health professionals and care management would enhance this process. Entries in the daily record did not routinely link to associated accident or incident records. 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. References were made to having meetings. A service user said he felt he was able to talk up at these meetings and would be listened to. Policy making and service development does not evidence active service user involvement although the manager said their wishes would be taken into account. Sumerlands H56-H06 S23592 Summerlands V225908 270605 Stage 4.doc Version 1.30 Page 12 A previous inspection recorded that any restrictions to personal freedoms would be recorded in the care plan. Some risk assessments had been carried out, both for the individual and environmentally. There is a need to carry out additional risk assessments, in particular in response to incidents. Risk assessments are easily accessible by staff. Staff have a good understanding of confidentiality. Service users were able to talk with the inspector in private. Records are held securely. This process would be enhanced by changing the recording format in the complaint record and by ensuring all entries in the communication book maintain full confidentiality. Sumerlands H56-H06 S23592 Summerlands V225908 270605 Stage 4.doc Version 1.30 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,15 & 16 Service users lives are enriched by a full programme of social, practical, recreational and educational activities EVIDENCE: Opportunities that arise during the day, both at Summerlands and external day care, to develop personal skills are encouraged. A service user spoke of starting to assist in cleaning his room. Service users said they did cooking, ‘maths’ and ‘English’, amongst other things, at the Counticare day service in Folkestone. Mention was made of using skills gained in a play. A group of service users had been rock climbing to Harrison Rocks in Tunbridge Wells that morning, one had a big grin on his face as he recounted it. A group spoke of going canoeing locally and how they enjoyed it. One service user said he had been to Eurodisney with staff and that he enjoyed the rides, especially Thunder Mountain. Others had been to Butlins at Minehead which they said they had chosen themselves. There is a small day unit at Summerlands which has a snoozelem. Some service users felt there was less to do in the evening. A minibus and estate car are based at Summerlands with a member of staff Sumerlands H56-H06 S23592 Summerlands V225908 270605 Stage 4.doc Version 1.30 Page 14 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. Many references were made to contact with family, some service users make regular visits home. Visitors are welcomed to the home at all reasonable times. Personal relationships were not discussed on this occasion. Staff respect service users rooms as private with locks which can be used by service users as appropriate. Bathrooms and toilets are lockable. Staff remind service users of the boundaries between rights and responsibilities, with both upheld as the occasion demands. The majority of service users have their finances managed through Counticare with monies individually named held in a combined dedicated account. Records of monies held for safekeeping were accurate with receipts linked to expenditure. The manager said that records were 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. From a comment seen this could result in monies being ‘borrowed’, although staff were aware this must not happen. Support workers carry out all catering on the premises. The main meal is normally in the evening but can be altered as necessary. A four-week rotating menu is used as a basis. Staff said this would be altered according to need and dietary needs would be met. On the day of inspection the meal was pasta. Service users thought the food was good. Packed lunches are made for those going out for the day. 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. Staff have an allowance for meals taken out with service users paid for out of petty cash. Local shops are used for general shopping. Service users said they help with shopping and look forward to the Mars bar and Coke which they get as a ‘reward’. Sumerlands H56-H06 S23592 Summerlands V225908 270605 Stage 4.doc Version 1.30 Page 15 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) Not inspected EVIDENCE: Sumerlands H56-H06 S23592 Summerlands V225908 270605 Stage 4.doc Version 1.30 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 Service users know they can complain and be listened to, the system would better evidenced if all complaints were recorded. 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. There should be consistency between the complaint procedures ensuring that information that the Commission can be contacted at any point in the process is recorded. A hardback complaint record is used which does not maintain confidentiality, nor allows additional paperwork to be included. The last complaint recorded was dated 25/10/02. Service users said they could make complaints in meetings or to their keyworker and normally they had a response. Sumerlands H56-H06 S23592 Summerlands V225908 270605 Stage 4.doc Version 1.30 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) 24,25,26,27,28,29 & 30 Service users enjoy an environment which suits them and is well maintained. Some work is needed to reduce the risks of cross infection. 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. There is ample space to move around freely, both inside and outside. A large patio area is accessed from the lounge doors and has tables and chairs. 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. Ground staff were mowing the grass. Counticare have their own maintenance staff who have been reported at other services as being very responsive. 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. Service users have single rooms where they can display their own effects such as posters. A service user said he had been given a ground floor room, as he wasn’t confident in using stairs. The four ground floor rooms are wheelchair accessible. A small group of Sumerlands H56-H06 S23592 Summerlands V225908 270605 Stage 4.doc Version 1.30 Page 18 service users transferred from an older property owned by Counticare and said they had been given first choice of bedrooms. Four bedrooms are en-suite. One ensuite was seen which was large with shower, washbasin and toilet. 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 upstairs bathroom has dual access, the manager said only one person who needs assistance is currently using this bathroom, hence staff would ensure the doors were secured appropriately. A toilet on the ground floor is for use by staff and visitors and occasionally used by service users. Aids and equipment as required are provided. References have been made to obtaining specialist advice such as from Kent Association for the Blind. There is separate laundry area which has dual access from the ground floor hallway and small rear room adjacent to the kitchen. Access would normally be locked with the senior holding a set of keys. 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. There is one sink which was stated as being used for hand washing but also used for emptying waste water and clothes hand washing. The risk of cross infection were further compromised by the lack of suitable soap dispensers, safe hand drying facilities and safe disposal facilities for potentially contaminated waste in the laundry and toilets. The manager said that fixed soap dispensers were on order. In addition, to reduce risks of cross infection, floor mops need to be stored correctly. Sumerlands H56-H06 S23592 Summerlands V225908 270605 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35 & 36 Service users are supported by staff who they know and like. That all staff are suitable to work in the home would be confirmed by better recruitment practices. 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. Why staff were offered a Team Leader post was not routinely evidenced. Staff refer for advice and support within the management structure. A similar structure is proposed for supervision, with those staff providing supervision to have supervision training. Currently the manager carries out all supervision. Supervision formats cover a range of work related issues including training needs. Staff have access to a range of training with a training matrix available. Counticare have their own training coordinator who was reported to ensure all staff have core and client specific training. A number of staff who deal with food handling do not have in date basic food hygiene training. This had been identified and training is planned. Records of induction were seen, the records did not evidence that staff, particularly without previous care experience, had Sumerlands H56-H06 S23592 Summerlands V225908 270605 Stage 4.doc Version 1.30 Page 20 followed a satisfactory induction process. Some staff are now undertaking the TOPPS induction procedure. Service users said they liked the staff and spoke of having their own keyworker. One keyworker has left, staff said that whoever was available would work with the service users involved until staff were recruited. A group of staff have worked at the home for some time, a few having transferred from the previous service and one from a sister home. Until recently there has been a stable staff team, two staff have recently left for personal reasons. One vacancy has been covered, recruitment is taking place for the other. The manager said that he does not like using agency or bank staff and they would be unfamiliar with the service users. Existing staff offer additional hours. On the day of inspection this system was resulting in two staff sleeping in rather than one wakeful and one sleeping as is normal. From discussion with staff and service users about night routines this is not acceptable, particularly as staff regularly work a late, sleep in and early shift. As mentioned staff rosters are flexible to meet service user need. A roster of planned and actual hours is held, the manager said that the record would be altered in July to include the role of each person. Counticare have a designated Human Resources department who advise on staff recruitment in conjunction with the home’s manager. Records of recruitment are held at the home as required. Where staff are transferred from another home there must be evidence of satisfactory recruitment procedures, including a copy of a full application form. The application form gives provision to record employment history, personal detail, experience and a full rehabilitation of offenders’ declaration. In one personnel file there was limited evidence of employment history or explanation of gaps in employment. Whilst the manager said this had been discussed at interview, as interview notes are not held this was not evidenced. The inspectors reminded the manager that two written references are required and there must be evidence that satisfactory references have been obtained before staff commence employment. There was discussion regarding Criminal Records Bureau disclosures, including the impact this might have on employment with vulnerable adults and the need to carry out risk assessments. All staff are employed on a three month trial period. Sumerlands H56-H06 S23592 Summerlands V225908 270605 Stage 4.doc Version 1.30 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 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) 37,38,41 & 42 Service users benefit from a safe and well run home. Their safety would be improved by attention to staff fire drills. EVIDENCE: As mentioned the manager has been in a managerial role at Summerlands for some 18 months, 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 and is in the final stages of being registered with the Commission as manager of Summerlands. The manager felt he was able to implement policies and procedures which were relevant to Summerlands. Policies were not inspected in sufficient detail to make a judgment as to their suitability. As the manager acts in a supervisory role to two other homes, responsibilities lie also within the senior team, including the Deputy. From evidence from Sumerlands H56-H06 S23592 Summerlands V225908 270605 Stage 4.doc Version 1.30 Page 22 previous inspection reports and from staff at Summerlands, service users benefit from an improved atmosphere, better recreational opportunities and 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. Records are generally well maintained and stored securely. Omissions have been mentioned earlier in the report and include staff personnel and recruitment records. Records of maintenance and servicing of equipment were not inspected. Fire safety and accident records were seen. Fridge and freezer temperatures are recorded on a daily basis. Both freezers needed attention, one regarding cleaning, the other the speed and level of ice build up. As recommended at the last inspection a lock has been fitted to the hatch between the dining room and kitchen. Hot water felt by hand from a hot water outlet was of safe temperature. The manager said hot water outlets are fitted with safety devices. Environmental risk assessments have been carried out including use of the lake. The inspectors asked that this include risk assessing access to the grounds by the public. There is security lighting around the outside of the home. Systems are in place to ensure service users safety is maintained including servicing of fire safety equipment and fire drills, which include service users, in case of fire. A few staff do not have evidence of attending a recent fire drill. A member of staff has responsibility for routine testing of equipment and is to ensure that regular weekly tests are carried out and recorded. Sumerlands H56-H06 S23592 Summerlands V225908 270605 Stage 4.doc Version 1.30 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 2 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 2 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 2 2 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 2 3 1 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 x Standard No 31 32 33 34 35 36 Score 2 3 1 1 1 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sumerlands Score x x x x Standard No 37 38 39 40 41 42 43 Score 3 3 x x 2 1 x H56-H06 S23592 Summerlands V225908 270605 Stage 4.doc Version 1.30 Page 24 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 1 (1) Regulation 4 (1) (c) Requirement The statement of purpose must include detail of actual staff employed and training/qualifications held by these staff. Systems and facilities must be put in place to reduce or remove the risks of cross infection, this will include: 1. Washbasins in those service users rooms which do not have en-suite facilities 2. Facilities of disposal of hazardous waste in toilets, including the staff toilet 3. Separate hand washing facilities, not used for other purpose, in all risk areas - to include soap dispensers, lidded and lined foot operated waste bins and hand drying facilities which are regularly maintained and which are designed to reduce the risks of cross infection. 4. Cleaning of the chest freezer 5. Attention to the frost build up in the upright freezer 6. Correct storage of floor mops Timescale for action To be actioned by 31 July 2005 and thereafter 1 - action plan to be received by 31 July 2005 2,3,4,5 & 6 – action to be completed by 31 July 2005 and continued thereafter 2. 30 (1) 13 (1) (3) Sumerlands H56-H06 S23592 Summerlands V225908 270605 Stage 4.doc Version 1.30 Page 25 3. 34 (1) 19 (1) & (4) 4. 35 (1) 18 (1) (c) 5. 33 (1) 18 (1) (a) Any person working or having regular contact with service users must follow a sound recruitment procedure, this will include: 1. Two written references being obtained for all employees, which should be in place before the employee commences work or evidence of a recorded verbal reference which is to be followed up by written confirmation. 2. Evidence that all employees have a validated employment history, with any gaps in employment verified, including the reason for leaving any previous work with vulnerable people 3. Where there are Criminal Records Bureau disclosures, there must be evidence that this has being risk assessed in relation to employment in the home and access to service users. All staff working in the home must have training appropriate to the work they are to perform. This will include: 1. There must be evidence that all staff have undertaken a planned and staged induction procedure which includes initial introduction to the service, takes into account the experience of the person recruited, the needs of service users and work practices in the home. 2. All staff handling food must have current food hygiene training. At all times the home must be staffed by sufficient, suitable and competent staff to meet the needs of service users. Given the current needs of the service user group this will include at least To be actioned by 31 July 2005 and thereafter 1: To be actioned by 31 July 2005 and thereafter 2: To be actioned by 31 August 2005 and maintained thereafter To be actioned by 31 July 2005 and thereafter Page 26 Sumerlands H56-H06 S23592 Summerlands V225908 270605 Stage 4.doc Version 1.30 one wakeful member of staff. 6. 41 (1) 17 (1) (2) & (3) All records relating to service users or staff must be available in the home for inspection at all times. This will include: 1. A copy of any agreement where a service user is paying an amount toward transport. 2. All recruitment documentation, including a complete application form. All staff must attend fire drills and practices at suitable intervals. This is recommended at not greater than 6 monthly intervals for day staff and 3 months for night staff. To be actioned by 31 July 2005 and thereafter 7. 42 (2) 23 (4) (e) To be actioned by 31 July 2005 and thereafter 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. 3. 4. 5. 6. Refer to Standard 1.1 6.1 9.1 9.3 10.1 22.1 Good Practice Recommendations The statement of purpose and service users guide should include detail of access by the public to the lake area. Care plans should reliably include guidelines to ensure all staff have a consistent agreed approach to behaviours which may challenge and health matters. Risk assessments should be carried out in response to incidents and accidents. Use of the lake area by the public should be risk assessed. The complaint record should maintain confidentiality and have space to include additional documentation relating to the complaint. The complaint procedures should be consistent with each recording that the Commission can be contacted at any time i.e. without the need to make initial contact with the service or organisation. All complaints should be recorded with detail of the investigation, outcomes and any resultant action taken. Where staff are offered promotion such as to Team Leader, there should be evidence of why this judgement was made in respect of skills, experience and personal qualities in H56-H06 S23592 Summerlands V225908 270605 Stage 4.doc Version 1.30 Page 27 7. 8. 22.1 33.1 Sumerlands 9. 10. 11. 34.1 42.3 42.7 relation to the work the person is to perform. As good practice in recruitment, record of interview questions should be held. Consideration should be given to stocking non hazardous materials, e.g. deodorants where provided for use by service users. There should be evidence that entries in the daily record have been followed up by accident or incident records as necessary. Sumerlands H56-H06 S23592 Summerlands V225908 270605 Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection The Oast, Hermitage Court Hermitage Lane Maidstone Kent 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 Sumerlands H56-H06 S23592 Summerlands V225908 270605 Stage 4.doc Version 1.30 Page 29 - 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. 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