Inspection on 29/06/06 for Summerlands

This inspection was carried out on 29th June 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Summerlands 17/07/08

Summerlands 20/07/07

Summerlands 01/02/06

Summerlands 08/07/05

Summerlands 06/01/05

Summerlands 12/07/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Summerlands 9 Villiers Road Southsea Portsmouth Hampshire PO5 2HG Lead Inspector Neil Kingman Unannounced Inspection 29 June 2006 10:00 Summerlands DS0000011856.V290507.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Summerlands DS0000011856.V290507.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Summerlands DS0000011856.V290507.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Summerlands Address 9 Villiers Road Southsea Portsmouth Hampshire PO5 2HG 023 9283 0682 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) Mrs Francesca Bilsland Miss Joy Michelle Tremayne Care Home 23 Category(ies) of Learning disability (23) registration, with number of places Summerlands DS0000011856.V290507.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users in the category LD must be at least 40 years of age One current, named, service user over 65 years of age can be accommodated. One current, named, service user in the category MD can be accommodated. 1 February 2006 Date of last inspection Brief Description of the Service: Summerlands is a Grade 2 listed building designed by the architect Thomas Owen and built in the 19th century. The interior and exterior of the home have numerous features of architectural interest. The building has been converted to provide care/support and accommodation for up to 23 people with a learning disability. The home is located close to, and between, Southsea shopping centre and the sea front, promenade and beach. Accommodation is set over four floors and consists of five single and nine double rooms. There is a stair lift between two floors. However, it does not extend to the lounge and dining room level. Therefore, rooms on the upper levels are not suitable for people with mobility difficulties. There is a pleasant walled garden with seating, accessible from the lounge and available for residents’ use. There is no off road parking but spaces can be found in side roads surrounding the home. Summerlands DS0000011856.V290507.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report details the results of an evaluation of the quality of the service provided by Summerlands and brings together accumulated evidence of activity in the home since the last key inspection on 1 February 2006. Part of the process has been to consult with people who use the service; including telephone discussions with three social services care managers and two relatives of residents who regularly visit. There were twenty-one responses to the care home’s survey received from residents in the home, most completed with the help of members of staff. Included in the inspection was an unannounced site visit to the home by an inspector on 29 June 2006. During the visit the inspector toured the building, looked at a selection of records, spoke with the manager, all staff on duty and several residents. At the last two inspections there were concerns about the environment and also staffing levels in the home. At this inspection the inspector focused on both those issues, with particular attention to the outcomes for residents. The responses from the consultations were very positive. What the service does well: The age range of the current resident group is 44 – 80 with twelve over 60 years of age. Several have been in the home for over twenty years. While at one time the home’s provision of opportunities for paid employment, training and further education would have been important standards to measure, lifestyle aspirations change with age. The results of this inspection should be looked at in the context of an ageing, long-standing resident group. Care managers described the service variously as: “Absolutely fine for my client. It’s worked really well”. “It’s old fashioned and suits some peoples’ needs”. “It’s somewhat institutional but suits those who live there”. “It’s good for my client who loves living there”. The home’s approach to personal planning is excellent. With so many Summerlands DS0000011856.V290507.R01.S.doc Version 5.2 Page 6 independent residents who wish to go out alone, good risk assessments are essential. Those viewed were of a high standard with clear guidance around maintaining residents’ safety. Staff unanimously agreed that the home was well managed. Regular meetings, supervision and training make for a motivated and stable staff group. What has improved since the last inspection? What they could do better: All shortfalls noted by the inspector relate to the environment. It is recognised by management that major work is required to bring the premises up to an acceptable standard. To this end the proprietor has confirmed that outline planning permission has been granted for the proposed work to be carried out. During which, many of the frequently raised environmental concerns would be addressed. However, some outstanding issues are required to be dealt with: • • • • The cracked sink in the attic bathroom presents a risk of cross infection and must be addressed. The one outstanding bed headboard must be fitted. The one outstanding old and worn armchair must be replaced. The old kitchen unit in the small lounge must be taken out and the room made more comfortable. Summerlands DS0000011856.V290507.R01.S.doc Version 5.2 Page 7 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 DS0000011856.V290507.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Summerlands DS0000011856.V290507.R01.S.doc Version 5.2 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 the following standard(s): 2 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Summerlands provides a service for long-term residents all of whom have been in the home for over five years. Those who live in the home have had their needs assessed and reviewed during that time. EVIDENCE: All residents have been at Summerlands for at least five years and all have been referred through Social Services care management. In discussions with the manager, although she has had no experience of introducing a new resident to this home she recognises the importance of a thorough preadmission assessment. Crucially, she showed an understanding of the need for prospective residents to feel comfortable in the home and be able to integrate with others who live there. The manager has a comprehensive preinspection assessment tool, which she said she would use with any new placement referrals. A needs assessment was available with each of the personal plans seen by the inspector. Summerlands DS0000011856.V290507.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service The manager has developed and agreed with each resident a personal plan, which they have signed. Plans are of a high standard and are based on an assessment of residents’ needs and wishes. The home does not place restrictions on the residents who can and do make decisions for themselves. They are encouraged to be as independent as possible and to take sensible risks, which enhance their enjoyment of life. EVIDENCE: The principal of case tracking was used in a sample of three personal plans. The intention was to look at the outcomes for residents in general by assessing all areas of care and support for those sampled. The sample included a female resident who had recently experienced health problems, one of the male residents and the oldest resident in the home. Summerlands DS0000011856.V290507.R01.S.doc Version 5.2 Page 11 The structure and content of the personal plans are of a high standard. Each resident’s plan contains an assessment of needs and skills and has objectives to be achieved. Weekly routines, day care, leisure, preferences etc., are all included. The inspector spoke with several residents. It was clear from the discussions that they are encouraged to make choices about activities in their lives, a good example being a resident who was looking forward to a coach trip to Buckingham Palace. While one resident is assessed as being able to manage her own finances the home takes responsibility for safeguarding others’ monies. The inspector looked at the integrity of the system in place and found it to be satisfactory. Risk assessments are also of a high standard. They are geared towards residents being able to take responsible risks. Being clearly set out they provide guidance on the action to be taken to minimise risks and avoid limiting the residents’ choice of preferred activity. Several residents go out independently from the home and risk assessments were seen to contain information on how they can do so safely. Summerlands DS0000011856.V290507.R01.S.doc Version 5.2 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): 12, 13, 15, 16 and 17 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged and supported to take part in a range of activities inside and outside the home, including opportunities for personal development, life skills and leisure. They maintain family links and outside friendships where desired. Routines in the home promote independence for the residents who have unrestricted access around the home. They are offered meals they enjoy, which are varied and healthy. EVIDENCE: The manager and staff confirmed that while many of the residents regularly attend day services, as they have aged none has maintained an interest in paid employment. The inspector viewed a weekly programme of activities for residents, which sets out the times, venues, means of transport and lunch arrangements. They benefit from involvement in local community groups, Summerlands DS0000011856.V290507.R01.S.doc Version 5.2 Page 13 including those specialising in ethnic minority needs. Two residents attend a local church on Sundays. Residents take part in a wide range of leisure activities, including evening and weekend clubs, visits to the pub, coffee bars and the shops. Some are encouraged to make these excursions alone, within a risk assessment framework. The inspector spoke with a relative/advocate of one of the residents who confirmed that the home has arranged annual holidays and trips away from the home. The talk during the site visit was of a show at the Portsmouth Guildhall attended recently by some of the residents. Menus sent to the Commission as part of the pre-inspection information show food for residents to be varied and nutritious, with choices of fruit and vegetables. Comments from residents about the food were positive. Residents help clear away the dishes and a few residents choose to help washup. The inspector observed some residents taking lunch in the dining room. The atmosphere was relaxed and jovial, and those taking time over their meal were not hurried. Summerlands DS0000011856.V290507.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents at Summerlands are for the most part independent and many are self-caring with encouragement where needed. The manager ensures that the residents’ healthcare needs are assessed and key workers enable and support them to receive healthcare checks at appropriate intervals. Medication is securely held and appropriate records maintained. EVIDENCE: A feature of Summerlands is the high level of independence enjoyed by nearly all residents regardless of age. Many are self-caring and need only encouragement to maintain their personal hygiene. It was clear from discussions with residents and staff that they have complete freedom of choice about getting up, going to bed and what they do during the day. Records show that specialist support and advice is sought as and when required. Summerlands DS0000011856.V290507.R01.S.doc Version 5.2 Page 15 Three care managers spoken with were full of praise for the way the home addresses residents’ healthcare needs. They described the manager’s knowledge and response to situations as excellent. Personal plans contain clear details for staff delivering any personal care. They include assessments of any moving and handling needs, personal hygiene etc. Residents confirmed that the home ensures they access healthcare professionals and records clearly show that each resident has regular appointments with the optician, dentist and chiropodist. A good example of the home’s rapid response to deterioration in a resident’s health is the relatively short time it has taken for a resident who had serious sight impairment to return to full health, and resume regular visits to the day service. Records showed that medication is administered by staff who have completed training in the safe handling of medicines. At the time of the site visit medication for residents was securely held, and records relating to its safekeeping and administration were found to be in order. Summerlands DS0000011856.V290507.R01.S.doc Version 5.2 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 and 23 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ complaints are treated seriously and given an appropriate response. The home’s policies, procedures and practices ensure that residents are safeguarded from abuse. Procedures for responding to suspicion or evidence of abuse are robust. EVIDENCE: The manager confirmed that no complaints have been made since the last inspection. The responses from residents in the care home’s survey show that everyone knows who to speak to if they are not happy and that they know how to make a complaint. Residents spoken with felt confident enough to speak with the manager, or any of the staff if they were worried about anything. A relative of one resident spoken with said she was not sure about the home’s complaints policy but had never had any concerns about the home, and would probably speak to the manager if she did. Another relative was very clear about taking concerns to the proprietor or the manager. The home has an adult protection policy and procedure, and staff training covers abuse and ‘whistle blowing’. Staff spoken with were very clear about how to recognise abuse, what to do, and the importance of reporting issues of concern without delay. Summerlands DS0000011856.V290507.R01.S.doc Version 5.2 Page 17 Summerlands DS0000011856.V290507.R01.S.doc Version 5.2 Page 18 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 and 30 - Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Summerlands is not purpose built but has been adapted over the years to provide a reasonably comfortable environment for people with learning disabilities. However, the building is old, very dated and in need of major investment and improvement. This makes the decoration and upkeep of the premises more difficult. There was evidence that since the last inspection some environmental concerns had been addressed. On the day of the site visit the home was clean, hygienic and mostly free from unpleasant odours, except in one room, the cause of which was explained by the manager. EVIDENCE: The inspector toured the building with the manager, principally to follow up on issues identified at the last inspection, but also to check for cleanliness and the state of the decoration. Issues identified at the last inspection include: Summerlands DS0000011856.V290507.R01.S.doc Version 5.2 Page 19 • Worn mattresses and pillows in some rooms were a cause for serious concern: All identified mattresses and pillows were seen to have been replaced. • There were chips in the bath enamel in the first floor bathroom. The chips have been repaired with proprietary enamel paint. • Worn and stained bed headboards needed to be replaced and new ones fitted to beds that had no headboards. All but one bed have an appropriate headboard. • To remove all damaged armchairs from bedrooms and either repair or replace them. All but one old and damaged armchair have been replaced with new. • The lack of a clear picture on the lounge television needed to be addressed. A fault with the television has been repaired. • The broken microwave oven in the kitchen needed replacing. A new microwave oven is in place. • Attention needed to be paid to the replacement of toilet lids and the provision of appropriate screening at bathroom windows. A cracked sink required repair or replacement. An effort has been made to give bathrooms a less institutional feel with the random use of decorative tile decals. However, the frosted glass windows still lack screening and the cracked sink has not been addressed. • The old and worn kitchen unit in the small lounge is wholly inappropriate and must be taken out. The room needs some attention to make it more comfortable. The inspector noted that half finished repairs to walls identified at the last inspection have been addressed. The environment at Summerlands has been the subject of concern at several previous inspections due mainly to the difficulty in maintaining modern day standards in an old and dated building. E.g., the drainage is original Victorian Summerlands DS0000011856.V290507.R01.S.doc Version 5.2 Page 20 and prone to blockages, the nine shared rooms limit residents’ options of choosing a single room, the basement dining room lacks natural light and presents as being dark and gloomy, the lack of a passenger lift would be problematic with an ageing resident group. The only criticism levelled at the home by visiting professionals has been the old and rambling environment. Following the last key inspection when serious environmental concerns were identified the proprietor and manager attended the offices of the Commission to discuss the way forward. The proprietor gave details of plans for a major development of the service. At this site visit the inspector was told that outline planning permission for the development has been granted. It is understood that the proposed development would bring the accommodation up to standard and address the concerns raised at recent inspections. The Commission recognises the impact a planned new development has on the general upkeep of an old building in a declining state as the last two inspections have identified significant shortfalls in environmental standards. While it is understood in light of the development proposals that major decoration and refurbishment in the building as it stands would not be cost effective, there are standards that must be maintained, especially those relating to the health and wellbeing of service users. It is important the registered person keeps the Commission updated with regular reports on the progress of the development, and in any event submits a timescale for the commencement of work by 31/10/06. During the tour of the building an unpleasant odour was noted in one room. The manager explained that it was due to a urinary infection contracted by a resident and was currently being treated. Summerlands DS0000011856.V290507.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff at Summerlands are deployed in adequate numbers and have the necessary skills and experience to meet the needs of the people who live there. Staff turnover is low and a robust recruitment procedure ensures residents are protected. EVIDENCE: The last four inspections have identified shortfalls in numbers of staff on duty in relation to the numbers and needs of the residents. The Residential Forum Guidance, which is a best practice guide to staffing levels, has been used to illustrate the gap between the recommended, and the actual staffing levels in the home. The manager confirmed that since the last inspection staffing levels have been reviewed and additional staff made available at weekends and at times when residents need support for trips and outside activities. Summerlands DS0000011856.V290507.R01.S.doc Version 5.2 Page 22 Staff rotas showed and the manager explained that on days throughout the week there are typically thirteen residents in the home and eight at various day services. Several of those who choose not to attend day services are independent enough to go out alone to the shops, coffee bars, or to friends and family. The inspector spoke with one such resident who had been out during the morning. There are two care support workers in the home during the day, with a cook and domestic staff. All care support workers were interviewed separately during the site visit. Three who had worked at Summerlands for several years described a marked improvement since their domestic duties were taken over about two years ago by dedicated domestic staff. They were very clear that sufficient staff were available to meet the needs of residents during the day. They said that providing the current flexible arrangements continued, whereby additional staff came in to facilitate trips out in the evenings, the needs and wishes of the residents would continue to be met. They all agreed that a third member of staff at the weekends was sufficient to supervise trips out for those who wanted them. A number of examples were given. One member of staff, who had worked at the home for only three months, described staffing levels as varied, and dependant on how many residents were in the home and how many needed support for trips out. The inspector spoke with three social services care managers who had visited their clients in Summerlands and carried out reviews of others. One said they could not really comment about staffing levels but felt there were always plenty around when they visited. Another was very clear that there were always enough staff at times when they visited, and the other said they had not noted any shortfalls. Visiting relatives of residents spoken with raised no concerns about staffing levels. Prior to the site visit the manager provided the Commission with a copy of the staff training plan, which gave details of training completed and scheduled. Mandatory training: Safe handling of medicines Infection control Health and safety First aid (appointed persons) Manual handling Food hygiene Fire training Key working and interaction skills Dealing with conflict and communication issues Proposed training: The pre-inspection information signed by the manager showed that 70 of the staff group had achieved the NVQ at level 2 or above. Summerlands DS0000011856.V290507.R01.S.doc Version 5.2 Page 23 In discussions with staff it was established that staff training is encouraged and provided. Two of the three care mangers consulted agreed that staff demonstrated a clear understanding of the needs of their client. The third thought half of them did. The inspector looked at the recruitment records of the one newly recruited care support worker recruited since the last inspection and found them to be in good order, with references and security checks in place. Summerlands DS0000011856.V290507.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well run by an experienced and qualified manager. While there are adequate quality assurance measures in place to ensure the home continues to meet its aims and objectives, they have yet to be implemented. The manager ensures the health and safety of the residents and staff as far as is reasonably practicable EVIDENCE: The registered manager has achieved the NVQ at level 4 in care and also the Registered Manager’s Award. She has many years experience of working with people with learning disabilities. Staff were very clear in discussions that the manager was both supportive and approachable. She ensures that regular staff meetings and formal supervision take place. Summerlands DS0000011856.V290507.R01.S.doc Version 5.2 Page 25 At the last key inspection it was noted the home did not have an effective quality assurance and quality monitoring system in place. At this site visit the manager described, and showed the inspector, the new quality audit system that had been developed but not yet implemented. It included a quality audit tool that was to be adapted to suit the service and feedback questionnaires to be completed at care reviews. Residents’ meetings are to be minuted. The manager said that due to the age of the building maintenance and redecoration tended to be reactive. She recognised that it was unlikely to change until the proposed development had taken place. All care support staff undertake statutory training, which includes health and safety, food hygiene, first aid and manual handling. The home’s pre-inspection information signed by the manager confirmed that policies and procedures were in place to ensure safe working practices in the home. At the last inspection a requirement was made to replace cloth towels and soap bars with paper towels and liquid soap. Liquid soap and paper towels are now in place in the kitchen and areas where staff wash their hands. Liquid soap is available in bathrooms and toilets. The manager said that due to the state of the old Victorian drainage system there was a strong likelihood that blockages would result from residents’ inappropriate disposal of paper towels. Therefore cloth towels were still in evidence in bathrooms and toilets, but according to the manager, were changed at frequent intervals. It is recommended that the Department of Environmental Health be consulted re: the acceptability of this practice. The inspector looked at fire logs, public liability insurance, health and safety risk assessments and a current electrical certificate, which were all in good order. Summerlands DS0000011856.V290507.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 x 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 2 x x 2 x Summerlands DS0000011856.V290507.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes 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 YA24 YA26 Regulation 23 • Requirement The cracked sink in the attic bathroom presents a risk of cross infection and must be addressed. • The one outstanding bed headboard must be fitted. • The one outstanding old and worn armchair must be replaced. • The old kitchen unit in the small lounge must be taken out and the room made more comfortable. (Elements of an outstanding requirement from the last inspection) Timescale for action 31/08/06 2 YA24 23 To keep the Commission updated 31/10/06 with regular reports on the progress of the development of the building, and in any event to submit a timescale for the commencement of work by 31/10/06. To implement the quality assurance system described by the manager during the inspection. 31/08/06 3 YA39 24 Summerlands DS0000011856.V290507.R01.S.doc Version 5.2 Page 28 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 YA42 Good Practice Recommendations To consult the Department of Environmental Health on the acceptability of the arrangements for hand drying in bathrooms and toilets. Summerlands DS0000011856.V290507.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight Ground Floor Mill Court Furrlongs Newport, IOW PO30 2AA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Summerlands DS0000011856.V290507.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!