Inspection on 08/10/07 for Summerville

This inspection was carried out on 8th October 2007.

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

Summerville 07/08/08

Summerville 09/08/06

Summerville 10/02/06

Summerville 21/06/05

Summerville 20/12/04

Summerville 12/07/04

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 Summerville 39 Prices Avenue Margate Kent CT9 2NT Lead Inspector Jenny McGookin Key Unannounced Inspection 8th October 2007 11:40 Summerville DS0000028712.V348658.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 Summerville DS0000028712.V348658.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. Summerville DS0000028712.V348658.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Summerville Address 39 Prices Avenue Margate Kent CT9 2NT 01843 295703 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) Manor Care Homes Rosario Vethanayagam Care Home 4 Category(ies) of Learning disability (0) registration, with number of places Summerville DS0000028712.V348658.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning Disability (LD) maximum number of places 4 The maximum number of service users to be accommodated is 4. Date of last inspection 19th January 2007 Brief Description of the Service: Summerville is a large detached property providing accommodation on two floors. There is a pleasant walled garden to the rear of the property with parking for 3-4 cars. Unlimited off street parking is available. The Home is situated within walking distance of some of the local amenities. The aim of the Home is to provide long term care for the service users enabling them to live as independently as possible in a homely and stimulating environment. The Home employs a registered manager and care staff. The staff carries out meal preparation and domestic work as part of their duties. At night there are waking night staff. The current fees for the service at the time of the visit range from £1,176 to £2,751.91 per week. Extra charges are payable for personal items such as: clothes, toiletries, extra leisure and social activities, therapeutic sessions (aromatherapy, yoga, music therapy). The home pays for one holiday a year. The service users would be liable to pay for a second. Information on the home’s services and the CSCI reports for prospective service users should be detailed in the Statement of Purpose and Service Users Guide. There is no e-mail address for this home. Summerville DS0000028712.V348658.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection site visit, which was intended to inform this year’s key inspection process; to review findings on the last inspection visit (January 2007) in respect of the day-to day running of the home; and to check compliance with matters raised for attention on that occasion. The inspection process took just over seven hours, and involved meeting with two senior support workers, and one nighttime support worker. The registered manager was not on duty that day. The inspection also involved a complete tour of the premises and the examination of a range of records. Two service users’ files were selected for care tracking. Conversations with the service users were limited in most cases by their level of disability. Feedback questionnaires were issued by the Commission, for completion by a range of stakeholders, and responses were received from one care manager, two relatives and two staff. These all invariably endorsed the inspector’s own findings. Interactions between staff and the service users were observed during the day. What the service does well: What has improved since the last inspection? The home has benefited by the organisational skills of the incoming manager, and the transfer of staff and service users from another home in the group, following its closure. The home is subject to a maintenance programme and more systematic staff training investments. Care planning documents make more conspicuous reference to other documents, to ensure a co-ordinated approach. Summerville DS0000028712.V348658.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Summerville DS0000028712.V348658.R01.S.doc Version 5.2 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 Summerville DS0000028712.V348658.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. 1, 2 Prospective service users are given some information needed to help them decide whether this home will meet their needs. The home has assessment tools in place, to ensure it has the capacity to meet service users’ needs. EVIDENCE: Since the last inspection, the home has revised its Statement of Purpose, which usefully describe the facilities and principles of care. There was good evidence on site, of work being done to reproduce key elements of the Service User Guide in a picture-assisted, accessible format, to meet the individual needs of the service users, but this work was not complete and will require trialling with individuals, to ensure they have the level of understanding they need. However, when assessed against the National Minimum Standards these documents were found to be not fully compliant. These matters were reported back to the home separately. Summerville DS0000028712.V348658.R01.S.doc Version 5.2 Page 9 Two of the current service users were admitted in 2002 and their admission process has been subject to assessment against the National Minimum Standards by inspections since then. The judgement was that this process was compliant with expected standards. The closure of another home in the group in May 2007 has meant that two service users were, more recently, transferred to Summerville. There was some information about the way both service user groups were introduced and supported to settle (consultation, joint visits and support to choose the décor of bedroom), but this process is not comprehensively documented in the individual files assessed. Each placement is subject to the terms and conditions of the contract the home has with the funding authorities, which are outside the scope of this inspection. There are currently no privately funded placements, and none in prospect. So the home’s own contract was not assessed on this occasion. Summerville DS0000028712.V348658.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 6, 7, 8, 9, 10 Service users benefit by being involved in decisions about their lives, and play an active role in planning the care and support they receive. Confidential information is stored securely. EVIDENCE: Two service users’ care plans were selected for closer examination. Their format is clearly designed to address all aspects of the service users’ health, personal and social care needs. And they usefully refer the reader to other documents such as risk assessments, behaviour guidelines, menus and finances, as well as to individualised programmes of activities and the home’s own P.I.P’s (Positive Interaction Profiles). The P.I.P’s are, moreover, written in the 1st person to keep the service user’s perspective central, and illustrated to assist their understanding. Summerville DS0000028712.V348658.R01.S.doc Version 5.2 Page 11 There was good evidence of periodic reviews, involving specialist agencies, to comply with expected frequency (six monthly). These documents usefully identify who participates in each case, and routinely review and amend objectives set at the previous review. The manager has been responsible for setting up the care planning processes, in the first instance, with input from staff, and has been training staff to take on this role. Each service user is allocated two members of staff – a key worker and a co-worker, to help build up a rapport and provide some continuity. There is active support from other agencies (see section on “Personal and Healthcare Support” for details). There has been no access to local advocacy services, so service users would need to rely on their key and co-workers or relatives to provide this. Records and feedback from staff confirm that the service users are supported to carry out some light domestic chores, like helping to tidy their rooms or carrying laundry, as well as to enjoy more recreational activities – all of which are likely to carry some inherent risk. There was good evidence of risk assessments governing a range of activities in respect of the two service users selected for case tracking, on and off site, and this covers key areas such as their ability to manage a door key, medication, travelling, and finances as well as the pre-emptive management of behaviours likely to place them or others at risk. Service users were observed being supported to make their own daily living decisions and accessing all communal parts of the home freely. The home’s arrangements for keeping confidential information secure against unauthorized access were judged satisfactory. Summerville DS0000028712.V348658.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 11, 12, 13, 14, 15, 16, 17 Service users benefit by the support they have to make choices about their life style, and to develop their life skills. Social, educational, cultural and recreational activities are designed to meet individual’s expectations. EVIDENCE: Employment may not currently be realistic prospects for these service users, given their level of learning disability, but college training opportunities have been accessed to good effect (see below). The service users show some understanding of the spoken word but have very limited communication skills. Staff interpret their responses and behaviours. Summerville DS0000028712.V348658.R01.S.doc Version 5.2 Page 13 Meetings with staff indicated a range of activities, tailored to the individual service users’ level of interest, on and off site. One likes to play darts, art sessions, Karaoke sessions and watching DVDs. He also likes to take out his collection of photos and reminisce. One likes puzzles, Connect 4, listening to music. One likes playing card games where he can point to pictures. He also enjoys head and shoulder massages. One service user pays to have music and exercise sessions on site. The conversion of basement facilities at another home in the group into a sensory room is likely to be of benefit to these service users and some have sensory equipment in their bedrooms. The home makes good use of its rear garden for gardening or picnics, weather permitting. Staff offer direct support in some light practical daily living skills (e.g. tidying, collecting laundry or crockery, shopping). The home has access to its own vehicle and is within reasonable access to community resources and events that implies i.e. there is good scope for activities not restricted to the service users’ disabilities. The service users go out for meals, walks and drives. They go bowling, swimming, shopping. One goes to college for drama, arts and crafts, and one room (which used to bathroom) has been converted into an arts and crafts room to enable her to continue with this and display her artwork. The home pays for one holiday for each service user each year (most recently Centre Parks), and service users pay for a second. There are open visiting arrangements. Records and feedback from staff confirm regular contact with relatives, and their active involvement in the care planning processes. The home has a payphone but service users have access to a cordless phone. The format of the care planning processes properly addresses the service users’ religious and cultural needs, and two attend a local Anglican church. Each individual’s nutritional needs and preferences are properly established as part of the care planning processes and carefully monitored and amended on a day-to-day basis thereon. Staff eat with the service users and eat the same food, which is judged a good quality assurance tool. During the site visit, the inspector joined two service users and staff for lunch and judged the meal well prepared and presented. The pace of the meal was unhurried and the atmosphere was relaxed and congenial. Service users have a choice over where they eat (one chooses to eat separately with staff, and has a dining table and chairs in another room), and they can snack between meals. Summerville DS0000028712.V348658.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 18, 19, 20 Service users benefit by the health and personal care they receive, which is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: The care planning processes and P.I.P’s assess the extent to which each service user requires assistance with their own personal and health care, and their choice and control is actively promoted by staff as far as possible. All the bedrooms are single occupancy and there are enough toilet and personal care facilities to guarantee their availability and privacy. Staff are available on a 24-hour basis to assist service users. The care planning process routinely addresses a range of standard healthcare needs (e.g. GP, dentist, chiropodist) and other healthcare professionals as Summerville DS0000028712.V348658.R01.S.doc Version 5.2 Page 15 appropriate (speech therapy, community nursing, epilepsy nursing, continence advice, occupational therapy and consultant psychology). The medication arrangements were assessed against the National Minimum Standards and found to be compliant. The home uses the Monitored Dosage System (MDS). There are twice daily checks (8am and 5pm), and there are stock control sheets for any non-MDS medication. Administration is signed for by two staff in each case, and there are periodic audits by senior staff. There were no apparent gaps or anomalies in the records kept, and each service user’s medication records are prefaced by a photo of them and information on their medication, all of which are designed as precautions against errors. Records and staff confirmed training investment. The home keeps a copy of the Royal Pharmaceutical Guidance and British National Formulary to underpin knowledge and practice. Summerville DS0000028712.V348658.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 22, 23 Service users are supported to express their concerns, and the home has a complaints procedure available to them in an accessible format. Service users are protected from abuse, and have their rights protected. EVIDENCE: The home has policies on complaints and adult protection, which have been judged satisfactory by previous inspections. There was also a picture-assisted version of the complaints procedure to make it more accessible to service users. However, there have only been two complaints registered over the last year. The absence of recorded complaints is not judged a realistic reflection of dayto-day life, given the special needs and interactions of the service users. The challenge continues to be to find ways of translating any expressions of dissatisfaction into recordable events, so that anyone authorised to inspect the records can evaluate the extent to which their responses are listened to and acted on. There is currently no active input from independent advocacy services, and the home relies on key and co-workers or relatives to represent the interests of service users. Summerville DS0000028712.V348658.R01.S.doc Version 5.2 Page 17 In meetings with the inspector, staff confirmed their commitment to challenge and report any instances of abuse, should they occur. Self-injurious behaviours by service users are judged appropriately managed. Summerville DS0000028712.V348658.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 24, 25, 26, 27, 28, 30 The physical design and layout of the home enable service live in safety, and encourages their independence. The property is generally well maintained and comfortable. EVIDENCE: The home’s location (in terms of access to community resources) and layout are generally suitable for its registered purpose, and measures are in place to keep the premises secure against unauthorised access or egress. All areas of the home were inspected and found to be homely, comfortable and clean. Comfortable temperatures and lighting levels were being maintained. The furniture tends to be domestic in style and there were homely touches throughout, including artwork by service users. Summerville DS0000028712.V348658.R01.S.doc Version 5.2 Page 19 The rear garden is landscaped to provide a pleasant outlook and opportunities for relaxation and recreation. This area is said to be used for picnics in good weather, and one service user has her own plot to tend. The home has a “No Smoking” policy. The communal areas of this home are spacious, and there is a choice of lounge and dining areas. The seating in the dining and lounge areas is uniform in style, but this is judged appropriate for the service users. The kitchen is light, airy, clean and well maintained. All the bedrooms are single occupancy. All the bedrooms were inspected and judged well maintained and personalised. In terms of their furniture and fittings, they were, however, generally not fully compliant with all the provisions of the National Minimum Standards. But non-provision was justified in each case (e.g. because of a propensity for seizures or outbursts). Service users have a choice of bath, shower and WC facilities. One bathroom requires substantial refurbishment and a double acting door lock, which could be opened in an emergency. On the day of this site visit, water temperatures were reported to sometimes get too hot, despite thermostatic mixing valves in all taps likely to be accessed by service users. With one exception, each bedroom has a wash hand basin. All the maintenance records seen were up to date and systematically arranged. The storage of substances hazardous to health was judged secure, and continence is managed effectively. The home uses continence sheets and alginate bags, and there were no unpleasant smell. An annual maintenance programme has been produced, which anticipate matters raised for attention by this site visit (see schedule of recommended action for details). Summerville DS0000028712.V348658.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users are benefiting from the training and support now being given to staff. Teamwork and flexible working enable staff to support the smooth running of the service. But staffing levels may be inhibiting support for service users at times. EVIDENCE: The following staffing arrangements apply. The morning shift is from 7.00am till 3.00pm; and the afternoon shift is from 1.00pm till 9.00pm. In each case there should be two support workers, so there is effectively some overlap between 1.00pm and 3.00pm. The manager generally works from 8.00am till 4.00pm. Overnight there is always one waking night staff, though recently one member of the afternoon shift has been staying on, on sleep-in duty but on call, to help manage one service user’s seizures and its impact on another service user. Summerville DS0000028712.V348658.R01.S.doc Version 5.2 Page 21 There are no ancillary staff. Support workers are responsible for cooking, laundry and cleaning the home. They are to be commended on the level of cleanliness found. The manager has taken the view that the overall staffing establishment is more than required. But these service users require 1:1 support at times within the home and 2:1 support to go out. So it is difficult to see how this can always be achieved on a day-to-day basis. One service user was observed, for example, sitting close to a radio or desk for large periods on the day of this site visit. Recruitment records could not be assessed on this occasion, as the manager was not on duty that day, and none of the staff had delegated authority to access them. The last key inspection in August 2006 had found significant shortfalls. But recruitment was reported to have been tightened up since then, and was now said to comply with the Learning Disability Award Framework and guidance from “Skills for Care”, on induction. Staff individually confirmed a robust recruitment process to comply with all the key elements of the standard. Staff confirmed that they had supervision sessions, usually every month (i.e. in excess of the National Minimum Standard), and that these sessions covered all those elements prescribed by the standard, specifically, the translation of the home’s philosophy and aims into work with individuals; monitoring or work with individual service users; support and professional guidance; and the identification of training and development needs. The manager was reported to be open and supportive. The manager has set up a training matrix and programme to cover mandatory training, and some specialist training, and staff said they felt generally well invested in. But there were several gaps in the records seen. 8/12 staff are reported to be accredited to NVQ Level 2 or above, with three more in prospect. Summerville DS0000028712.V348658.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. 37, 38, 39, 42, 43 The service users benefit by the management and administration of the home, which is based on openness and respect, The quality of the service provided has yet to be assessed by stakeholders. EVIDENCE: Mrs Vethanayagam has been the registered manager of Summerville since 28th June 2007. She was not on duty on the day of this inspection, but the Statement of Purpose states that she has worked with people with learning disabilities since obtaining her nursing qualification in 1978 and was a registered Home Manager in the 80’s and 90’s; that she holds Management and NVQ Level 4 qualifications gained both in the health service and the Summerville DS0000028712.V348658.R01.S.doc Version 5.2 Page 23 private care sector. Rosario Vethanayagam is also a qualified tutor and NVQ assessor/ internal verifier. There was good evidence of Mrs Vethanayagam’s organisational skills. The processes for managing this home are judged open and transparent. Staff feedback indicates that the delegation of responsibilities is appropriate, but there needs to be someone with full delegated authority to access records in her absence for inspection purposes. There was good evidence of service users being supported to make choices on a day-to-day basis, but the last available quality assurance initiative was in respect of another home in the group, before its closure, and will require revisiting once the service users who transferred from that home have had time to properly settle in Summerville. The proprietor will need to demonstrate a better level of compliance with his regulatory responsibility to carry out his own inspection visits at least once a month – there were several gaps in the records seen and breach of this regulation is listed as an offence. This matter has been raised for attention by the Commission before. The Proprietor has separately written to the Commission with a summary statement about the future of this service. But there should also be a unitspecific business plan, linked to quality assurance initiatives and corporate business planning and auditing arrangements, to obtain full compliance with this standard. The views of service users and other stakeholders will be crucial to the success of this. See Standard 22 on complaints. The challenge will be to demonstrate, through proper record keeping, that issues causing dissatisfaction are listened to and acted upon. Records confirmed that the home has been subject to health and safety audits. The home appeared to be generally very well maintained and hazard free. All maintenance records were up to date and systematically stored. Summerville DS0000028712.V348658.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. 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 2 2 2 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 2 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 2 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 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 3 2 X X 3 1 Summerville DS0000028712.V348658.R01.S.doc Version 5.2 Page 25 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 YA1 Regulation 4 5 sch 1 Requirement The Statement of Purpose will require amendment to obtain full compliance with the National Minimum Standard. Sufficient numbers of care staff must be provided at all times to meet the service users needs and comply with their care plan. These levels must be kept under regular review. Previous timescale: 31/05/06 & 15/09/06, 30/03/07 An annual quality assurance programme needs to be completed. Previous timescale: 31.12.05 & 30/06/06 & 30/11/06, 30/03/07 To check the level of staff required per service user in accordance with their funding contract and ensure this is complied with. Previous timescale: 30/03/07 Timescale for action 31/12/07 2 YA33 18 28/02/08 3 YA39 10 12 15 24 31/12/07 4 YA33 18 28/02/08 Summerville DS0000028712.V348658.R01.S.doc Version 5.2 Page 26 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 YA24 Good Practice Recommendations Building. The following matters are raised for attention: • Sensor lighting at the back, though this needs replacement / re-wiring. • Kitchen. One window pane cracked. There should be fly screens or an insectocutor. Should be a dishwasher. • One bathroom / WC requires refurbishment. Standard bolt on door – needs double acting lock Ceiling light requires diffuser. • Three bedroom ceiling lights require shades or diffusers • Damage to one bedroom door should be repaired • Vacant bed room – requires refurbishment. Needs a lockable space Regular audit need to be conduct with a record of the findings and action taken produced. There should be a unit-specific business plan, linked to quality assurance initiatives and corporate business planning and auditing arrangements, to obtain full compliance with this standard. The views of service users and other stakeholders will be crucial to the success of this 2 3 YA20 YA39 Summerville DS0000028712.V348658.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Summerville DS0000028712.V348658.R01.S.doc Version 5.2 Page 28 - 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!