Inspection on 04/01/07 for Sutton Leaze

This inspection was carried out on 4th January 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sutton Leaze 13/10/05

Sutton Leaze 02/06/05

Sutton Leaze 07/09/04

Sutton Leaze 20/04/04

Sutton Leaze 31/07/02

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 Sutton Leaze Eastbourne Road Seaford East Sussex BN25 4BB Lead Inspector June Davies Key Unannounced Inspection 4th January 2007 10:00 Sutton Leaze DS0000021234.V320506.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 Sutton Leaze DS0000021234.V320506.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. Sutton Leaze DS0000021234.V320506.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sutton Leaze Address Eastbourne Road Seaford East Sussex BN25 4BB 01323 894301 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) suttonfields@onetel.com Southdown Housing Association Limited Gary John Biddlecombe Vacant Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Sutton Leaze DS0000021234.V320506.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is five (5). Service users must be aged between eighteen (18) and sixty-five (65) years on admission. Only service users with a learning disability are to be accommodated. Date of last inspection Brief Description of the Service: Sutton Leaze is part of the Southdown Housing Association and is registered to provide accommodation and care to five adults who have a learning disability. The home recently changed its name from Sutton Fields to Sutton Leaze. The home is an attractive wooden construction bungalow, which is set back from the main road in to Seaford. The location of the home offers easy access to Seaford town centre. The home has two vehicles, and public transport links are within walking distance. Each service user has their own bedroom, which is decorated to their individual preference. Four of the bedrooms have en-suite facilities. One bedroom with en-suite facilities is a large, spacious room in the attic. There are two lounge areas, a conservatory and a kitchen/dining room. There is one communal bathroom located on the ground floor. A secure and well-maintained garden is situated at the rear of the property. The home does not provide level access throughout, however the current service users are mobile and are able to move freely around the house. Service users do not attend formal day care, but access a wide range of services offered by local colleges, organisations and the home itself. Fees charged £ 1,090 to £1,551.00 Sutton Leaze DS0000021234.V320506.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection carried out over a period of five hours, the inspector spoke with some of the residents, staff, and registered manager, observed staff working with the residents, and giving out medication. The inspector also saw care plans and other documentation relevant to the standards inspected. The inspector also contacted two the resident’s families and one social worker by telephone to ensure they were happy with the care that the residents receive in the home. What the service does well: All documentation relevant to the residents in the home is informative and kept up to date, with good risk assessments in place and regular reviews of care plans carried out. Residents are given choices in their everyday lives, and this includes activities and outings. They are able to voice their opinions with the support of staff at regular weekly resident meetings. The health care of the residents is well met, and there was evidence on each individuals care plan that members of the multi disciplinary teams are involved in working with the home to ensure that residents receive all the health care they require. Medication within the home is well managed, with good accurate records kept of the medication that the residents receive. Residents are able to choose the food they would like to eat, with guidance from the staff team to ensure that the residents receive a balanced and wholesome diet. The home is well maintained, decoration in the home is good, furniture and soft furnishing are of good quality, and the home is bright and cheerful. Staffing levels in the home are good. Over half the staff have gained NVQ level 2 or above. Both the registered provider and the registered manager ensure that quality assurance in the home is monitored on a regular basis. Health and safety in the home is good, with up to date maintenance checks carried out to all appliances used in the home, and checks on fire systems, hot water temperatures being carried out regularly by the staff. The inspector spoke with a social worker and two parents on the telephone to obtain their experience of the care provided by the home responses were the home is ‘outstanding’, better than we would have expected’, ‘we can find no fault with the care given to our son’, ‘the staff are very good’, ‘we are always made so welcome when we visit’, ‘the residents in the home have so many activities they take part in’, ‘we have got to know the staff in the home very well’, and ‘the staff team is static, and that must help the resident to have familiar faces around them’. Sutton Leaze DS0000021234.V320506.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sutton Leaze DS0000021234.V320506.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 Sutton Leaze DS0000021234.V320506.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): Standard 2 Quality in this outcome area is good. Needs assessment highlight individual’s specific requirements. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No new residents have been admitted to the home for four years. The registered manager was able to describe the procedure for the assessment of a prospective resident, and was able to show the inspector the policy and procedure and assessment forms that would be used. Assessment forms were comprehensive and would give a good insight into the level of care that a prospective resident would need. Sutton Leaze DS0000021234.V320506.R01.S.doc Version 5.2 Page 9 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): Standards 6, 7 and 9 Quality in this outcome area is good. Care plans are individual for each resident giving clear information as to the care both personal, physical and social that each resident requires. Residents are assisted by staff to make choices in the way the home is run and in the activities they wish to participate in. Risk assessment give clear guidelines to ensure that any risk to a resident is kept to a minimum. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each service user have their own individual care plan, these care plans describe the aims and objectives of the care to be received, long term setting conditions, involvement with family/friends and significant others, triggers to behaviour, behavioural support, likes and dislikes, daily routine, risk management including a variety of individual risk assessments around daily living and activities, an up to date medication history, health needs, verbal and non verbal communication, and members of multi disciplinary team that will be Sutton Leaze DS0000021234.V320506.R01.S.doc Version 5.2 Page 10 involved in the service users care. Care plan were seen to be regularly reviewed every six months, one review involves the registered manager and key worker and the annual review involves, registered manager, key worker, family and members of the multi disciplinary team. Service users are able to make choices in regard to their everyday lives. There is a weekly residents meeting which gives each resident the opportunity to raise any issues or comment on the way the home is run. At this meeting the residents are able to make choices as to who they wish to support them and the activities they will take part in, and which outing they wish to go on including where they wish to go. All but one of the residents’ need to communicate via pictures and photographs, and each resident has their own picture/photograph tin to assist them with their communication to members of staff. Some residents are able to use Makaton signing but this is also supported by the use of pictures and photographs. None of the residents due to their disability are able to take complete control of their own finances and the reasons for this are documented in their care plan. Each care plan had completed and informative risk assessments relating to a wide range of activities and opportunities both in the home and in the local community. There was evidence to show that risk assessments are regularly reviewed and changed to meet the needs of each resident. New risk assessments are developed as and when the need is required and recognised by the registered manager and staff team. Risk assessments were viewed and gave clear guidelines to staff as to how the element of risk can be reduced. Sutton Leaze DS0000021234.V320506.R01.S.doc Version 5.2 Page 11 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): Standards 12, 13, 15, 16 and 17. Quality in this outcome area is good. Links with the community are good and support and enrich residents’ social and educational opportunities. The manager and staff understand the importance of encouraging residents to maintain links with their families and friends and these links are well maintained. The routines of daily living include the residents and enable them to make choices and maintain their independence. Dietary needs of residents’ are well catered for with a balanced and varied selection of food available that meets the residents’ tastes and choices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Evidence was available via residents care plans, discussion with staff and one resident that they are supported to pursue educational courses of their own choice. All college activities can be evidenced within the residents individual Sutton Leaze DS0000021234.V320506.R01.S.doc Version 5.2 Page 12 care plans. The home also had a weekly timetable of activities that residents have chosen to take part in and this also includes their chosen college courses. Each day residents have some link with the local community, visiting the local shops, cafes, pubs, cinemas, theatres, hydro pool, and walking. During weekly meetings staff inform the residents of any forthcoming events that the residents might be interested in. Sutton Leaze is one of a group of homes in the area, and residents are able to meet with other residents from other homes in a purpose built club, which offers discos, sports days, or using the café club just for a drink with friends. Staff are available both in the evenings and at weekends to ensure that residents receive support for activities outside the home at these times. Every Saturday residents go on a trip of their choosing and have lunch out. On most Saturday evening’s residents are able to attend a disco if they wish to. One resident chooses to attend church on a Sunday. When residents go out into the community they are supported by one or two members of staff. The registered manager and staff do all they can to ensure that residents maintain contact with their families and friends. Evidence was available on each residents’ care plan to show that the residents do have regular contact in the form of telephone calls, letters and visits from their close families and friends and this was also verified via telephone calls made by the inspector to some of the families. All residents are able to move about the home as they wish to. During the course of the inspection the inspector witnessed that staff respect residents privacy and dignity, by knocking on bedroom doors before entering. Staff call residents’ by their preferred names. All resident’s bedrooms have locks but staff are able to gain access in the case of an emergency. Staff said that residents’ always open their own mail, but the staff are available to help them with the reading and explaining the contents of letters. The inspector witnessed members of staff interacting with the residents, using Makaton signing, pictures and photographs, non of the staff on the day of the inspection spoke to one another and excluded the residents from their conversation. The registered manager told the inspector that one resident sometimes goes to his own room in the evenings, so that he is able to listen to his own preference in music, and watch his own selection of television programmes. The gardens of the home are very well laid out and secure for use by the residents in the home, both the registered manager, one resident and staff told the inspector that the residents love to go into the garden when the weather is nice. Care plans showed that residents are involved in housekeeping tasks around the home, generally with the support of the staff, and these housekeeping tasks are also set as goals within individual care plans. Residents help to clean their bedrooms, make a cup of tea, help with the preparation of meals, and keep the communal area clean and tidy. Sutton Leaze DS0000021234.V320506.R01.S.doc Version 5.2 Page 13 The home has a five week rolling menu, residents are able to choose what they would like to eat, some of the residents use picture cards to indicate what their choice of food will be, but if this choice is cooked and the resident does not want it, he is offered another choice. The inspector viewed the menus and found that they were well balanced and nutritious. All residents are offered a cooked breakfast as well as toast and cereals, cooked lunch, a cooked evening meal and an evening snack. All meals taken by individual residents are recorded, and residents’ weight is taken on a regular basis. Meals are cooked to fit in with the residents’ daily activities. At the present time the home does not cater for specialised diets, but would be able to do so if the need arose. Sutton Leaze DS0000021234.V320506.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): Standards 18,19 and 20. Quality in this outcome area is good. Personnel support in this home is offered in such a way as to promote and protect the residents’ privacy, dignity and independence. The health needs of the residents’ are well met with evidence of good multi disciplinary working taking place on a regular basis. The medication in the home is well managed promoting good health. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff observe the privacy and dignity of the residents when delivering personal support, this was evidenced the inspector on the day of the visit. None of the residents in the home needs specialised support when mobile; some just need the arm of a member of staff for reassurance when mobile. Personal care is given in the privacy of the resident’s own bedrooms or in the communal bathroom. Residents are able to choose their own time of going to bed in the evening and getting up in the morning, especially at weekends, when the residents do not need to go to college. All the service users needs some degree of support with their personal hygiene, and the level of support required is recorded in each individual resident’s care plan. The residents are Sutton Leaze DS0000021234.V320506.R01.S.doc Version 5.2 Page 15 able to choose which clothes they would prefer to wear on a daily basis. At the weekly resident meetings the residents’ are able to choose which staff they would like to be supported by especially when going out into the community. Evidence was available in care plans to show that residents’ receive assistance from physiotherapist, psychologists, learning disability nurse, speech and language therapist. Staff were able to confirm that should a resident need assessment from a psychiatrist, or community psychiatric nurse, this would be done through referral from the resident’s general practitioner. All residents’ receive a consistency of care, through key workers, care plans which state their likes and dislikes and the way that residents are able to communicate, and there was also evidence that families with the consent of the residents are involved in annual reviews. Each resident has their healthcare needs recorded in their individual care plan. None of the residents’ through their disability are able to take control of their own healthcare and are supported by the registered manager and staff to do this. Each resident is registered with a local general practitioner. Evidence was available in care plans and supported by staff to show that residents have access to a variety of health care professional, including the learning disability nurse and epilepsy nurse. The registered manager told the inspector that the residents G.P. carries out a well man health check every three years, but the manager is in discussion with the G.P. to obtain more frequent health checks for the residents in the home. Each resident visits their own chiropodist, optician and dentist on a regular basis again these visits are well recorded in each care plan. Due to the nature of the residents’ disabilities none are able to administer their own medication. The inspector carried out an audit of the medication administered in the home, and found that all medication is appropriately recorded when received, administered and returned to the pharmacy. A double check is kept of each resident’s medication, and there are separate PRN records kept and signed when this medication is administered. The home uses the MDS method of administration from their local pharmacist. All staff have received medication training, which is regularly updated. One member of staff administers medication and signs the MAR sheet, and another member of staff witnesses and signs the medication sheet, the inspector witnessed this during the visit. The home has a recently reviewed comprehensive medication policy and procedure, and there is a list of all staff, with their signatures and initials. At the present time none of the residents in the home take controlled drugs, but a support worker on duty, clearly explained to the inspector and knew the process of administering controlled drugs and would know what to do should they be prescribed. Sutton Leaze DS0000021234.V320506.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): Standards 22 and 23. Quality in this outcome area is good. The home has satisfactory complaints systems in place to ensure that residents feel that their views are listened to and acted on. Staff have a good knowledge and understanding of adult protection issues, which protects the residents from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a recently reviewed and easily accessible complaints policy and procedure, which sets out, what to do if you need to make a complaint, the time in which a complaint will be responded to, and who the complainant can go to if they are not happy with the response. The complaints policy and procedure is also written in picture form to make it more accessible for the residents in the home. Since the last inspection the home has received two complaints. The complaint was investigated by the registered manager and the company’s area manager and responded to within the time scale set out in the complaints policy and procedure. The registered manager told the inspector that the residents very rarely need to make a complaint as any minor grumble is sorted out on a daily basis or at the weekly residents meetings. The inspector spoke with members of resident’s families, who were very happy with the care their residents received in the home. The home has robust policies and procedures in place to protect the residents from all forms of abuse and these have been reviewed in the last year. There Sutton Leaze DS0000021234.V320506.R01.S.doc Version 5.2 Page 17 have been no adult protection issues since the last inspection. Staff are made aware of what constitutes abuse on their induction and adult protection training is to take place within the next few months. Staff also have a clear whistle blowing policy and procedure, which informs them how to raise any issues or concerns for the protection of the residents. Sutton Leaze DS0000021234.V320506.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): Standards 24, 26 and 30 Quality in this outcome area is good. The standard of the environment within the home is good providing the residents’ with an attractive and homely place to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection the home was clean and tidy, and there were no offensive odours. The inspector noted that the home was kept in good condition, and furniture and fittings were domestic in style. Overall the Sutton Leaze had a homely welcoming atmosphere. Communal rooms which consisted of two small lounge areas, a large conservatory, a large kitchen diner, and ground floor communal bathroom and toilet where are in good decorative order, and bright and cheerful. Sutton Leaze DS0000021234.V320506.R01.S.doc Version 5.2 Page 19 The inspector viewed three residents bedrooms all were individually decorated and furnished to meet the interests and style of the individual residents. All furniture was of good quality and in good condition. One resident’s bedrooms had been designed on a bed sit basis, this is because the resident likes to spend a lot of time in his room, listening to his choice of music and watching his choice of television programme, to accommodate this the room has been designed with a bed which is in a cupboard and can be pulled down for sleeping purposes, but during the day when the bed is put away, the resident has a very comfortable sitting room in which to pursue his own interests. On the day of the inspection the home was clean and tidy and free from any offensive odours. Staff were aware of the importance of infection control, and there were policies and procedures in place to inform staff of what they need to do to prevent the spread of infection. Sufficient hand washing facilities were available for staff. The laundry room was situated in a separate room off the kitchen area. Any foul laundry is washed at appropriate temperatures to prevent cross infection. The laundry room has impermeable floor, and the inspector noted that it was tidy and well ordered. Staff are provided with protective clothing to deal with any spillages. Sutton Leaze DS0000021234.V320506.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): Standards 32, 34 and 35 Quality in this outcome area is good. Staff morale is high resulting in an enthusiastic workforce that works positively with the residents to improve their whole quality of life. Staff are multi skilled ensuring good quality care and support. Recruit practices are consistent resulting in residents receiving care from staff who have been appropriately vetted. The arrangements for the induction of staff are good with the staff demonstrating a clear understanding of their roles. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff team have the experience and knowledge to ensure that residents’ assessed needs are met. The inspector observed and talked to staff during the inspection. Staff communicated well with the residents in a friendly and professional manner. Three residents were taken out by members of staff who were on duty during the inspection and the inspector observed staff giving clear and patient guidance to the residents to prepare them for going out. All staff have received job related training and this was evidence via the training Sutton Leaze DS0000021234.V320506.R01.S.doc Version 5.2 Page 21 matrix. 69 of staff have NVQ level 2 or above, with other staff registered onto a NVQ course. All paperwork relevant to the recruitment of staff is kept at the companies head office, but the registered manager was clearly able to describe to the inspector how staff are recruited, and did have written evidence that all staff are CRB checked prior to taking up employment. No references are accepted addressed to ‘Whom it may concern’, and prospective employees have to give the name and addresses of two referees, for the company to apply for written references. All prospective employees need to complete a full employment history on their application forms and the registered manager confirmed that at interview all gaps in employment are fully explored. All new staff are given a copy of the GSCC code of conduct. The inspector was shown the staff-training matrix, while the majority of staff have completed all mandatory training some staff still required training whilst other staff needed to update their training, and the inspector is making a requirement that all staff receive and update mandatory training to ensure they are fully compliant. All staff are given induction training, and this was evidenced by the inspector via the training matrix, because the staff team in the home are long serving the majority have completed TOPPS induction training, but any new employees will now be required to complete Skills for Care induction training. Sutton Leaze DS0000021234.V320506.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): Standards 37,39 and 42 Quality in this outcome area is good. The manager is well supported by the senior staff in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. Quality assurance checks including questionnaires are in place ensuring the home provides a good quality of care for the residents in the home. The manager and staff are aware of the importance of regular monitoring of health and safety to ensure that the residents live in a safe environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has recently completed his NVQ level 4 and RMA and is currently awaiting his certificates. He has been a manager of the home for two years. The deputy manager is in the process of completing her NVQ level Sutton Leaze DS0000021234.V320506.R01.S.doc Version 5.2 Page 23 4. Staff spoke highly of the management team. The registered manager ensures that through other training he is able to update his skills and knowledge to meet the needs of the residents. The inspector viewed the quality assurance file, and found it to be comprehensive with a wide range of quality assurance monitoring taking place. Included with the file was a – Provider Business Plan, Quality monitoring check carried out by the Area Manager together with an action sheet, and a review to ensure actions had been taken, relative questionnaire sheets, resident questionnaire sheets in picture form (Key workers help the residents to complete these), a safety audit, audit of residents personal monies, fire risk assessment, NHS medication audit and the staff training record updated when staff have completed training. The inspector also noted that within the file was a summary report on the quality assurance questionnaires. The majority of staff have completed training related to health and safety – moving and handling, fire safety, first aid, food hygiene and infection control, but the inspector noted there were some gaps and a requirement has been made under standard 35. The inspector was able to view up to date maintenance certificates for appliances and equipment used in the home as follows this included gas appliances, electrical circuit testing 2002 (due this year 2007), PAT testing, Legionella testing on. There had been regular weekly checks of the fire alarm system, a fire drill had been held in October 2006, Fire Officer inspection in 2006, the car used for resident outings has regular weekly checks and hot water checks. Also available were Health and Safety checklist risk assessment carried out in November 2006, Health and Safety walkthrough inspection also carried out in November 2006 and COSHH risk assessment carried out in 2006. The premises is secure, with a number lock fitted to the front door, and all gates giving access from the back garden to the front of the premises are securely locked. Window restrictors are fitted to windows. There were policies and procedures in place relating to health and safety and all had been reviewed in 2006. The inspector noted that the home had an EHO accident book with all accidents to residents being recorded, and reported to the relevant persons when necessary. All staff receive thorough induction which includes health and safety issues. Sutton Leaze DS0000021234.V320506.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 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 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Sutton Leaze DS0000021234.V320506.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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. YA35 18(1)(a) Standard Regulation Requirement All staff receive mandatory training and update this training as required. Timescale for action 05/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Sutton Leaze DS0000021234.V320506.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone Kent 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 Sutton Leaze DS0000021234.V320506.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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