Inspection on 05/07/07 for Sunnyside House

This inspection was carried out on 5th July 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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sunnyside House 04/01/07

Sunnyside House 04/07/06

Sunnyside House 26/01/06

Sunnyside House 28/09/05

Sunnyside House 04/03/05

Sunnyside House 20/09/04

Sunnyside House 18/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Sunnyside House Main Road Birdwood Glos GL19 3EA Lead Inspector Ms Lynne Bennett Unannounced Inspection 5 and 6th July 2007 10:00 th Sunnyside House DS0000055006.V336721.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 Sunnyside House DS0000055006.V336721.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. Sunnyside House DS0000055006.V336721.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sunnyside House Address Main Road Birdwood Glos GL19 3EA 01452 750491 01452 750405 sunnyside@orchardendltd.co.uk www.orchardendltd.co.uk Orchard End Limited 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) Mr Robert Theobald Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Sunnyside House DS0000055006.V336721.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th January 2007 Brief Description of the Service: Sunnyside provides accommodation and personal care to ten people who have learning disabilities and some who may also have additional challenging behaviours. The home is divided into two separate living areas; the main house that can accommodate six service users and the bungalow which can accommodate four service users. All service users have single rooms. There are spacious grounds around the home. The home is set back from a busy main road in a rural village with some local amenities nearby. Service users are supported to use public transport and the home’s own transport to access a variety of community facilities in Gloucester and the Forest of Dean. The home is part of the group of homes known as Orchard End Limited, which is a subsidiary of C.H.O.I.C.E Limited. Fee levels at the home range from £1,121 to £1,863. The Statement of Purpose and last inspection record are kept in the office. Each person living at the home has a personal copy of the Service User Guide. Sunnyside House DS0000055006.V336721.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This inspection took place in July 2007 and involved two visits to the home on 5th and 6th July. The home presently does not have a registered manager, a registered manager from another home is overseeing it, and he was present for part of the first visit. The deputy manager and area manager were present during the visits. The home’s psychologist was also available. Time was spent talking to people living at the home and observing the care they receive. Staff were also interviewed and a handover observed. Comment cards had not been returned at the time of the visits and the area manager requested additional copies to distribute. A copy of the Annual Quality Assurance Assessment was provided during the visits. A range of records were examined including care plans, medication and financial records, staff files and health and safety records. Monthly reports made by the provider (Regulation 26 visits) and notifications to the Commission (Regulation 37) records previously supplied to us also provided evidence for this inspection. What the service does well: What has improved since the last inspection? Each person has a personalised copy of the reviewed Statement of Purpose and Service User Guide that includes a copy of their terms and conditions. There has been a significant reduction in the use of physical intervention. Staff are more confident in the use of de-escalation and diversion techniques. Sunnyside House DS0000055006.V336721.R01.S.doc Version 5.2 Page 6 People living at the home said that they express concerns or make complaints at house meetings and to management in the knowledge that they will be listened to and acted upon. The bungalow has been refurbished creating new shower, bathrooms and kitchen. Fixtures and fittings are of a high standard. Considerable work has been completed at the main house. The conservatory now provides three separate rooms including an additional communal area. Recruitment procedures involve people living at the home helping out with staff interviews. Systems have been put in place to ensure that any gaps in employment history are questioned at interview. Quality assurance systems involve people living at the home and there is evidence that their views have been listened to and action taken to resolve issues such as helping to interview staff. 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. Sunnyside House DS0000055006.V336721.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 Sunnyside House DS0000055006.V336721.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): 2 and 5. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The needs and aspirations of people wishing to move into the home are fully assessed before they are offered a place at the home. People have access to information about the service they will receive including a statement of terms and conditions. EVIDENCE: The home presently has one vacancy for which it is considering a person over 65. The area manager explained the process for admission that includes a visit to the person to complete an assessment, initial referral information from the placing authority that will be followed by an assessment and care plan. These documents were not available for inspection. A copy of the assessment used by the home was examined. Visits to the home were being arranged, two having taken place and another one planned for the week after the inspection. People living at the home have had the opportunity to meet with this person. This was confirmed in the Annual Quality Assurance Assessment and in conversation with management. These visits also form part of the assessment process. If the person moves into the home the Statement of Purpose and Service User Guide will need to be reviewed to reflect the change in age range of people living at the home. The area manager confirmed that training is being resourced for staff in the care of older people. Sunnyside House DS0000055006.V336721.R01.S.doc Version 5.2 Page 9 Each person has been given a copy of the revised Statement of Purpose and Service User Guide that includes a copy of their terms and conditions. Some people have signed these documents. Sunnyside House DS0000055006.V336721.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): 6,7 and 9. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are being involved in making decisions about their lives and as person centred planning is introduced these opportunities are likely to increase. Risk management plans safeguard people from hazards and allow them to take responsible risks. EVIDENCE: New person centred plans are being introduced in the home which will create greater opportunities for people to become involved in the planning of their care. One plan had been put in place and this was sampled. Three people were case tracked, this involved reading their care plans, talking to them and staff about how their needs are met and observing the care they were receiving. Plans identify how the physical, intellectual, emotional and social needs of people are to be met. The Annual Quality Assurance Assessment confirmed that they are devised in a multidisciplinary way that involves people living at the home. Sunnyside House DS0000055006.V336721.R01.S.doc Version 5.2 Page 11 Where hazards or behavioural issues are identified the plan clearly links to risk management plans or support guidelines. For instance one person’s plan indicated that they might become anxious, the risk management plan gave staff guidance on how to minimise this and what strategies to use. This was observed being used in practice. Daily diaries also indicated how staff had effectively supported this person and indicated the use of behaviour observation charts and an accident report being completed. All documents were examined clearly cross-referencing to each other. Care plans and risk management plans are regularly reviewed and there was evidence of annual reviews with placing authorities. Daily notes for one person indicated that they had been ‘touchy feely’ with staff. Although their care plan indicated that they might intimidate other people living at the home there was no comment about interactions with staff. There were also no guidelines for staff on how they should deal with this situation. The psychologist confirmed that guidelines would be developed. The terminology used in some daily diaries and behaviour observation charts was discussed with the deputy manager. She said that the home’s psychologist is planning a session with staff to discuss suitable language to use and the appropriate content for these records. People said they have regular house meetings and this was confirmed in the Annual Quality Assurance Assessment. Staff said that people choose their meal options for the week at these meetings. People were observed being offered choices and making decisions about their daily lives such as helping with shopping, cleaning or their activities for the day. Most people are supported to manage their finances. Detailed records are kept of expenditure and money being credited. Staff check balances each day and sign that the balance is correct. Two finance records were examined and receipts cross-referenced with bank statements and these records. They were satisfactory. The deputy manager confirmed that bank statements are checked each month although there is no evidence that this is being done. There was evidence that finances are audited as part of Regulation 26 visits and ongoing improvements to the systems of administration are identified. Each person is having their inventory of possessions updated by their key workers. The deputy manager confirmed that there are very few restrictions in the home except perhaps access to the kitchen in the bungalow and this is recorded in the relevant care plans. During the visits access to food was restricted to safeguard one person and although people have access to keys to cupboards to obtain food it did appear to be causing some anxiety. This had not been identified in care plans. The Regulation 26 report indicated that the area manager had discussed the recording and rationale of restrictions with the deputy manager and that these would be recorded. Sunnyside House DS0000055006.V336721.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): 12,13,14,15,16 and 17. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are able to make choices about their life style and supported to develop life skills. People have the opportunity to participate in social, educational, cultural and recreational activities that reflect their personal expectations. EVIDENCE: There was great excitement in the home during the visits as people had returned from a recent holiday and others were planning to go on holiday. Staff were observed planning the holidays minimising possible risks and reducing people’s anxieties. People confirmed that they had been involved in choosing their holidays and some people were already discussing their next vacation. People were also observed popping out to the local garage, pub and garden centre. Daily records confirmed that for some this is a regular occurrence. One person said they like to go and buy their cigarettes and another person Sunnyside House DS0000055006.V336721.R01.S.doc Version 5.2 Page 13 said they enjoy going for a coffee and cake. One person was also involved in helping staff with the weekly food shop in Gloucester. Some people have jobs around the home for which they receive payment. These range from cleaning the home’s vehicles to putting the rubbish out. People are also involved in helping to clean their rooms and communal areas. They may also help with their washing. Some people have programmes of support in their care plans that give step-by-step goals to learn independent living skills such as washing their clothes or using the microwave. People discussed the range of opportunities they are offered including going to church, college, swimming and using the leisure centre. One person said they enjoyed going rock climbing and another person was trying out a sample of college courses. Some people have also been involved in accompanying the area manager on Regulation 26 visits to other homes in the area. They said they really enjoyed this. Where people refuse activities this is recorded in their daily notes. For those people who wish to spend time at home there is a computer with internet access which is very popular. A home tutor also visits regularly and people have aromatherapy massage each week. One person enjoys walking around the grounds and others are being encouraged to help develop the garden. There are plans to develop an area for growing vegetables in high beds which would be more accessible to people. People said that they enjoy going to social clubs in the Forest of Dean where they are able to meet with friends. Some people invite friends back to the home. There was evidence in people’s care plans of staff proactively supporting people to maintain relationships with friends. Close contact is supported with family and staff were taking several people home for regular visits. Any visits or communication are recorded in care plans. People are involved in the choice of menu and thought has been given to ensuring that this reflects the cultural background of all people living at the home. Although food is locked away to safeguard one person who has an eating disorder, people appeared to have access to keys to store cupboards. Anxiety was caused when a particular item could not be found immediately but staff managed to calm the person and find the item in the bungalow. People were observed helping themselves to snacks and drinks throughout the visits. A variety of fresh meat, vegetables and fruit were in good supply. People enjoyed meals of fish and chips and chilli con carne. Alternatives are provided if needed. People’s meal choice is recorded in their daily diary. In addition to the facilities in the kitchen, a kettle has been provided in the conservatory. The kitchen in the bungalow has been completely refurbished with the intention of enabling people to prepare their own meals. Staff said that one person is already making their breakfast and drinks in this kitchen. Sunnyside House DS0000055006.V336721.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): 18,19 and 20. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care people receive is based on their individual needs and increasingly being provided in the way in which they prefer. EVIDENCE: The new person centred plans will clearly identify the way in which people would like to be supported listing their likes and dislikes, making this information more accessible to staff. Despite this staff spoken with had a good understanding of the needs of the people they support. Times for getting up and going to bed are flexible dictated by each person’s daily activities. People are supported to express their individuality through their choice of clothes and the way in which they have personalised their rooms. Staff make sure that the needs of the only female are respected supporting her with her personal care in a discreet manner. Refurbishment of the bathroom in the bungalow has helped in this area considerably. Each person has a health action plan which is being developed with the cooperation of the local doctor’s surgery. Details are also kept of each person’s healthcare appointments. Some people choose not to attend appointments Sunnyside House DS0000055006.V336721.R01.S.doc Version 5.2 Page 15 and the reasons are recorded. Records confirm close working with the local Community Learning Disability Team and management indicate that the relationship with the team has significantly improved. The systems for administration of medication were examined and found to be satisfactory. Weekly medication audits have been put in place. It was evident that any issues identified during these are discussed with staff and appropriate action taken as a result. Staff have completed the ‘care of medicines’ course and have an annual assessment of competency. At the time of the first visit the temperature of the medicine cabinet was not being monitored. A thermometer and recording chart were put in place immediately. Each person has consented to have their medication administered by staff. The Annual Quality Assurance Assessment indicates that some people may wish to start administering their own medication in the future. Sunnyside House DS0000055006.V336721.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): 22 and 23. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are confident in the knowledge that any concerns they may express will be listened to and acted upon. Systems are in place that safeguard people from possible harm or abuse. EVIDENCE: The home has received seven complaints over the last twelve months, six from people living at the home and one from a neighbour. The outcomes and action taken for each complaint has been recorded. People living at the home said that they would speak to staff or management if they have any concerns. One person was observed being supported to express concerns during the visit and complete a complaints form. People said they would also talk about concerns at the house meeting. A group of staff have recently attended training with Gloucestershire Adult Protection Team in the safeguarding of adults and further staff are due to complete this. The deputy manager is due to attend the enhanced training. Discussions with staff indicated that they have a good understanding of the issues and their role in reporting suspected abuse. All staff attend training in MORE (Management of Response to Emotion) and senior staff have completed training in IABA (Institute of Applied Behaviour Analysis). The result is a significant decrease in the use of physical intervention in the home with only two incidences being recorded over an eight-month period. This is a considerable improvement. Staff spoke Sunnyside House DS0000055006.V336721.R01.S.doc Version 5.2 Page 17 confidently about using de-escalation and low arousal techniques and using physical intervention as a last resort. They were observed using these techniques effectively during the visits. Where people may be at risk of self-harm support guidelines are in place providing staff with guidance to minimise these risks. Any changes to behaviour are noted and the appropriate healthcare professionals involved in a reassessment of risk management plans. Sunnyside House DS0000055006.V336721.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): 24 and 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people to live in a safe, well-maintained and comfortable environment that encourages independence. EVIDENCE: Significant improvements have been made to the environment over the past twelve months. There is considerable wear and tear on the home due to the nature of the people living there. During the visits there were three holes noted in walls which occurred during the visits and action was taken to repair these immediately. The overall impression of the home is one that is now cared for and kept in a good state of repair. The management team said that access to day-to-day maintenance has improved and that any issues are dealt with and actioned as quickly as possible. Maintenance requests are processed electronically and monitored at Regulation 26 visits to the home. Sunnyside House DS0000055006.V336721.R01.S.doc Version 5.2 Page 19 In the main house areas have been redecorated and new fixtures and fittings supplied to the main lounge. New flooring has been laid in the hallway and new carpet in the lounge. The conservatory has been totally refurbished creating three separate areas housing a laundry, food store and communal area. The bungalow has been redecorated throughout. New washable floors have been fitted in the hallways. The shower room and bathroom have both been completely refurbished. The kitchen has been fitted with new units and supplied with a new cooker Considerable effort has also been made to tackle the grounds and utilise the large areas of overgrown land. Rubbish has been cleared away from the bungalow and parking area and the sheds have been tidied. A sun house has been built in the garden to provide additional office or meeting space. At the time of the visits the home was clean and tidy. Some staff have completed infection control training and colour coded mops and buckets and personal protective equipment is provided. Hand scrub is provided throughout the home. Sunnyside House DS0000055006.V336721.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): 32,34 and 35. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Recent improvements in recruitment and selection procedures will safeguard people from possible harm. Staff have access to a robust training programme which will equip them to meet the needs of people using the service. EVIDENCE: There are currently four staff vacancies for which the home is recruiting. The remainder of the staff team have a mix of experiences and skills with some people new to care and others with considerable experience and knowledge. A NVQ programme is running with six people working for their awards and five people with a NVQ. Discussions with staff confirmed their understanding of the needs of the people they support that was verified by observation of their practice during the visits. Recruitment and selection is operated in line with the organisation’s procedures. One file was available for examination of a person who had left the home after a short period. An application form provided evidence that gaps in employment history were obtained. Questions asked at interview also query such gaps. The area manager confirmed that a further gap between Sunnyside House DS0000055006.V336721.R01.S.doc Version 5.2 Page 21 leaving school and obtaining a job had been acquired after employment having been identified as missing during a Regulation 26 visit. Staff are not appointed until two satisfactory references and a Criminal Records Bureau check are in place. People living at the home said that they have been involved in the interviewing of new staff. Each new member of staff completes an induction programme. The Annual Quality Assurance Assessment identified that this needs to have a more structured approach. Staff confirmed that they had shadowed other staff initially and had completed M.O.R.E. training as part of their induction. A training matrix is maintained which identifies when staff need refresher training. There was evidence that this is being provided. Staff also confirmed that specialist courses in autistic spectrum disorder, epilepsy and mental health are provided. Staff have attended mental capacity act training. Sunnyside House DS0000055006.V336721.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): 37,39 and 42. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Effective quality assurance systems are in place that involve people living at the home with evidence that their views are underpinning improvements and developments within the service. Regular monitoring of health and safety systems ensures that any unsafe practice is identified and action is taken to rectify this. EVIDENCE: The registered manager has recently left the home and the vacant position is being advertised. In the interim the deputy manager and a manager from another home in the group are managing the home. Sunnyside House DS0000055006.V336721.R01.S.doc Version 5.2 Page 23 A quality assurance system is in place that involves the people living at the home. The Annual Quality Assurance Assessment states that comments from the last survey expressed concerns that: • they were not involved in the admission of new people to the home • they were not involved in the selection of new staff • they did not have enough say in the running of the home. As a result regular house meetings are now held, people meet with people thinking about moving into the home and people help to interview new staff. The area manager confirmed that the annual quality assurance would take place later in the year giving managers time to meet the agreed timescale of their development plans. Monthly-unannounced Regulation 26 visits take place including people from other homes. Health and safety systems are in place with responsibility being delegated to key staff who have received the appropriate training. Regulation 26 reports confirm that records are being monitored during these visits. Fire risk assessments are in place but still refer to people staying put in their rooms. This had been identified for review but had not been done at the time of the visit. Two staff have attended the ‘safer food better business’ course and are responsible for stock control and the hazard analysis for the premises. Food in the fridge was labelled correctly with the date of preparation or opening. The freezer in the kitchen was being defrosted due to irregularities in the temperature. Some of the items from this freezer had been opened but not properly re-sealed or labelled with date of opening. This was dealt with immediately. Sunnyside House DS0000055006.V336721.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 X 2 3 3 X 4 X 5 3 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 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 2 X 3 X X 2 X Sunnyside House DS0000055006.V336721.R01.S.doc Version 5.2 Page 25 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 YA6 Regulation 15(2)I Requirement Timescale for action 05/09/07 2. YA7 17(1)(a) Sch 3.3(q) 3. 4. YA39 YA42 8(1) 23(4A)(b) Care plans must be kept up to date giving staff guidance on how to deal with inappropriate behaviour from the people they support. Where people have restrictions 05/09/07 to accessing food the reasons for this must be recorded indicating why this is in place and how people can get access to food and snacks. A manager must be appointed 05/09/07 and an application forwarded to the Commission for registration. A fire risk assessment must be in 05/09/07 place that complies with the Regulatory Reform (Fire Safety) Order 2005. People who use the service must be evacuated to a safe place if fire breaks out in the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Sunnyside House DS0000055006.V336721.R01.S.doc Version 5.2 Page 26 No. 1. 2. 3. Refer to Standard YA6 YA7 YA42 Good Practice Recommendations The appropriate terminology should be used in reporting which is respectful of people living at the home and objective. When bank statements are checked they should be signed or initialled to provide evidence that this has been done and transactions are correct. Opened produce or food should be labelled with the date of opening and boxes closed or fastened to protect the produce inside. Sunnyside House DS0000055006.V336721.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Sunnyside House DS0000055006.V336721.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. 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