Inspection on 24/07/07 for The Seagulls

This inspection was carried out on 24th July 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 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Seagulls 13/12/06

The Seagulls 15/11/05

The Seagulls 04/05/05

The Seagulls 14/09/04

The Seagulls 01/06/04

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 The Seagulls 6 Crowborough Road Saltdean East Sussex BN2 8EA Lead Inspector Nigel Thompson Key Unannounced Inspection 24th July 2007 09:30 The Seagulls DS0000021406.V343207.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 The Seagulls DS0000021406.V343207.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. The Seagulls DS0000021406.V343207.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Seagulls Address 6 Crowborough Road Saltdean East Sussex BN2 8EA 01273 390610 01273 308672 pedniki@yahoo.co.uk 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 Driss Zemouli Ms Niki Clarke Ms Niki Clarke Care Home 6 Category(ies) of Learning disability (6) registration, with number of places The Seagulls DS0000021406.V343207.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is six (6). Service users should be aged between eighteen (18) and sixty-five (65) years on admission 13th December 2006 Date of last inspection Brief Description of the Service: The Seagulls is a well-appointed detached property situated in a residential area close to the main coast road and cliff tops at Saltdean. The home is registered to provide care for six adults with a learning disability; it does not provide nursing care. The owners have another home nearby and there are often joint activities between the two homes. Local shops and amenities are a short walk away and bus services to Brighton and other areas run close by the home. Parking is freely available in the street outside. Accommodation is provided on two floors, with two bedrooms on the ground floor and five rooms on the first floor. Communal areas include a comfortable lounge and a separate dining room, which is also used as an activity room. There is a smoking conservatory leading out to a pleasant garden situated at the rear of the property. The fees charge range from £600 per week and are based on an individual assessment of care needs. Included in the fees are all usual hotel costs and the cost of staffing a supported holiday. Additional charges are made for Hairdressing from £6.50 per cut, personal toiletries, newspapers and magazines, an annual holiday approximately £200 - £300 a year, chiropody £18 per month, outings £8 - £10 per week and live shows approximately £45 per year. A copy of the last Inspection report is available upon request from the manager of the home. The Seagulls DS0000021406.V343207.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection took place over five and a half hours in July 2007. It found that the majority of the key National Minimum Standards that were assessed had been met or partially met and the overall quality of care provided was good. Service users observed and spoken with during the inspection expressed satisfaction with the home, the staff and the service provided. The purpose of this inspection was to assess compliance with the requirements of the previous inspection and to generally monitor care practices at the home. On the day of the inspection there were five service users living at the home. The inspection involved a tour of the premises, observation of working practices, examination of the home’s records and discussion with three service users, three members of staff, the Registered Manager and the Registered Provider. Responses from a CSCI service users’ survey, regarding their views on the home and quality of care provided, now form part of the inspection process and have also been included in this report. The focus of the inspection was on the quality of life for people who live at the home. What the service does well: Residents at The Seagulls clearly benefit from having an experienced manager and dedicated staff team who are evidently committed to providing a consistent level of care. Staff work closely with service users and have developed a sound understanding of their individual care and support needs. The relaxed, homely and welcoming environment has evolved over many years and reflects the commitment within the staff team and the open and inclusive management style. Residents are encouraged and supported to make decisions about their lives. They are involved and regularly consulted on many aspects of life in the home, including menu planning and activities. The Seagulls DS0000021406.V343207.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Formal staff supervision – regular and structured one-to-one meetings with individual care staff and their manager – must be introduced, as required, to ensure that staff have the appropriate skills, knowledge and understanding of residents’ individual care and support needs. The safety of residents and staff within the home would be improved by the fitting of automatic door closures. It is recommended that a copy of the complaints procedure be made available for the benefit of resident’s relatives and other visitors to the home. The Seagulls DS0000021406.V343207.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Seagulls DS0000021406.V343207.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Seagulls DS0000021406.V343207.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The thorough admission policy and procedure ensures that service users are admitted only on the basis of a full needs assessment, undertaken by people competent to do so. Prospective service users know that the home is able to meet their individual care and support needs. EVIDENCE: Although there have been no service users admitted to The Seagulls since the previous inspection, comprehensive information relating to the home is made available to all prospective service users, their relatives and associated care managers. Relevant documentation including an updated Statement of Purpose ‘ and ‘Service User Guide’ was examined and found to be satisfactory. Clear admission criteria and a thorough pre-admission assessment of each prospective service user, which incorporates a comprehensive breakdown of all The Seagulls DS0000021406.V343207.R01.S.doc Version 5.2 Page 10 personal, emotional and social care needs, ensures that all identified needs can be met. The manager confirmed that The Seagulls continues to maintain a good working relationship with the local Community Learning Disability Team (CLDT), who consequently have a sound understanding and awareness of the suitability of the home and the range and quality of the services provided. A referral to the home from the CLDT consists of a thorough Social Care Assessment and any additional relevant reports. The manager will also visit the prospective service user and carry out a full pre-admission assessment, including any personal and emotional care and support needs, mobility issues, social and cultural needs and family involvement. In addition to establishing whether the individual’s care and support needs can be met within the home, the manager also stressed the importance of ensuring compatibility with existing service users. As well as being invited to visit the home to look around and meet with existing residents and staff, prospective service users have the opportunity to stop overnight before moving in. The manager confirmed that all new service users undergo a three month trial period at the home, during which time their suitability and compatibility are fully assessed and it is established whether their identified care and support needs are able to be met. Since the last inspection, as required, the ‘Contract of Residence’ has been reviewed and amended to include details of costs and a statement of terms and conditions. In documents that were examined it was evident that individual agreements had been signed and dated by the resident themselves or a relative or representative on their behalf. The Seagulls DS0000021406.V343207.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users’ care plans enable staff to meet assessed needs in a structured and consistent manner and individual plans, including risk assessments reflect changing support needs. Systems for consultation and participation remain effective and service users are treated with respect and encouraged and enabled to make decisions about their day-to-day living. EVIDENCE: Staff spoken to during the inspection confirmed that, despite the variable and limited verbal communication of many residents, effective and regular interaction and consultation takes place constantly throughout the home. This was evident from direct observation of staff supporting service users in a professional, sensitive and respectful manner. The Seagulls DS0000021406.V343207.R01.S.doc Version 5.2 Page 12 The manager confirmed that the individual resident themselves, their key worker and, where appropriate, a relative or representative have the opportunity to be involved in regular care plan reviews. In plans that were examined, it was evident that recent reviews had taken place. Care plans were also found to be comprehensive and linked to the individual’s current assessments, containing detailed guidance for staff on how to meet their care and support needs in a structured and consistent manner. A welcome development since the previous inspection has been that care pans are now printed out instead of being hand written, which clearly makes information far more readily accessible to staff. Independence and individuality is evidently encouraged and promoted within the home and is reflected in the personalising of service users’ rooms, the choice of bedclothes and colour schemes and individual preferences for occupational and leisure activities. The Seagulls DS0000021406.V343207.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users are enabled and supported to maintain contact with family and friends as they wish and effective links with the community enrich their social and educational opportunities. Service users benefit from generally appropriate recreational and leisure activities and menus that are balanced and nutritious, reflecting their individual likes and preferences. EVIDENCE: The recreational and leisure interests of service users are identified and recorded in their individual care plan and they continue to be supported to access activities and facilities, reflecting their individual needs and abilities. A weekly activities programme has been developed and implemented for each service user and a copy is contained in their individual care plan. However it is The Seagulls DS0000021406.V343207.R01.S.doc Version 5.2 Page 14 not evident how relevant or appropriate certain ‘activities’ are, including ‘Learning to read and write’ or how they reflect individual interests and preferences. All service users enjoyed a holiday in Kent earlier in the year and one resident is looking forward to visiting Germany in September. Community participation remains a focus in the home and service users are evidently encouraged and supported to visit the cinema, theatre, local shops and other amenities. The manager confirmed that, where appropriate, service users’ family links are encouraged and supported, however not all service users have regular family contact. Visiting to the home is largely unrestricted and relatives and friends are made welcome at any reasonable time. Since the previous inspection, as required, menus have evidently been comprehensively reviewed. They are varied and balanced and are based on service users’ identified likes and preferences. An alternative to the main meal is always available. As part of the redevelopment process, the format for menus has also been improved to be more accessible. Daily menus are now printed out and make effective use of coloured photographs of individual meals. Service users spoken with during the inspection expressed satisfaction with the standard and variety of meals provided: ‘The food is good – I like it’. The Seagulls DS0000021406.V343207.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Staff have developed close and positive relationships with service users and demonstrate an awareness and sound understanding of their individual care and support needs. Service users are protected by clear and comprehensive policies and procedures in place for the control and safe administration of medication. EVIDENCE: The manager emphasised the importance of staff developing close working relationships with individual service users and being aware of changes in mood or behaviour. Documentary evidence was in place to demonstrate that the health and emotional care needs are continuing to be met within the home. The Seagulls DS0000021406.V343207.R01.S.doc Version 5.2 Page 16 Since the previous inspection, as required, specific and detailed guidelines have been drawn up for all care staff, with respect to diabetes and epilepsy. It is evident that in developing these guidelines advice has been sought from relevant professionals, including the Diabetes Nurse Specialist. Following discussion with the manager it is recommended that all guidelines be signed and dated by staff to confirm that they have read and understood the information. All service users are registered with local GPs and have access to other health care professionals, including district nurses, physiotherapists and dentists, as required. It was noted, in care plans that were examined, that all appointments with, or visits by, health care professionals are appropriately recorded. The manger confirmed that the home continues to maintain a close professional relationship with the locally based Community Learning Disability Team who are able to provide relevant guidance and help with appropriate staff training, including epilepsy awareness. Up to date, detailed policies and procedures relating to the control, storage, administration and recording of medication are in place. Medicines are stored and recorded appropriately. All staff responsible for administering medication have received training and are individually assessed and authorised to do so. The manager confirmed that, following risk assessments, no service user currently self-administers their own medication. The Seagulls DS0000021406.V343207.R01.S.doc Version 5.2 Page 17 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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home’s complaints procedure ensures that service users, staff and visitors feel able to express any concerns, confident that they will be listened to and acted upon. Service users are protected, through policies and procedures relating to abuse and adult protection. EVIDENCE: A clear, simple and concise complaints procedure has been developed. However, for the benefit of service users’ relatives and other visitors to the home, it is recommended that a copy of the procedure be displayed in a more prominent position. All complaints are recorded and include actions taken and outcomes achieved. Close working relationships, effective and ongoing communication and consultation and regular service users’ meetings provide adequate opportunities for any concerns to be raised and discussed, before they become complaints. Service users and members of staff, spoken with during the inspection, confirmed that they would have no hesitation in speaking to the manager or The Seagulls DS0000021406.V343207.R01.S.doc Version 5.2 Page 18 making a complaint if necessary and each person was confident that they would be listened to. Following discussion with the manager it is recommended that a copy of the complaints procedure be made available for the benefit of resident’s relatives and other visitors to the home. It was noted that there have been no concerns or complaints recorded by the home since the last inspection. The home has produced detailed policies and procedures, recently reviewed, relating to adult protection and abuse, including a whistle blowing policy. These documents have evidently been drawn up in accordance with the multi agency guidelines for the protection of vulnerable adults (Safeguarding adults). The manager and all care staff, except two, have recently undertaken appropriate training regarding abuse awareness and adult protection procedures. The manager confirmed that the remaining two members of staff will receive the training later this year. This was supported through discussions with members of staff during the inspection and evidenced through individual training records. The Seagulls DS0000021406.V343207.R01.S.doc Version 5.2 Page 19 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, 25, 26, 28 & 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The service is accessible, safe and clean and remains clearly suitable for it’s stated purpose. Service users benefit from pleasant accommodation that is comfortable, generally well maintained and decorated to a satisfactory standard. EVIDENCE: There have been some notable changes made to the physical environment of the home since the previous inspection, including a new roof, several replacement radiators, refurbishment and redecoration. The Seagulls DS0000021406.V343207.R01.S.doc Version 5.2 Page 20 During my ‘guided tour’ of the premises it was evident that the generally well maintained décor and adequate furniture and furnishings continue to provide a comfortable, pleasant and homely environment for service users. The entrance hall, stairs and first floor corridor have evidently been redecorated since the last inspection. It was also noted that the kitchen, lounge, dining room and downstairs washroom have recently been repainted. The manager confirmed that independence and individuality continue to be promoted within the home and this is evident from the personalising of service users’ individual rooms, reflecting individual preference and interests. It was noted that infection control policies and procedures are in place and clearly adhered to. On the day of the inspection, levels of cleanliness and hygiene throughout the home were found to be satisfactory The Seagulls DS0000021406.V343207.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 &36 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. There is always sufficient trained and competent staff on duty to meet the assessed needs of the service users. Service users are protected by satisfactory staff recruitment policies, procedures and documentation. EVIDENCE: Through discussion with the manager and care staff, it is evident that sufficient staff are employed to meet the current assessed needs of residents and to ensure consistency and continuity of care. The manager confirmed that staffing levels are closely monitored and are directly linked to service users’ levels of dependency. Since the previous inspection, as required, a duty rota has been developed and implemented to detail the staff on duty at any given time and their designation. The Seagulls DS0000021406.V343207.R01.S.doc Version 5.2 Page 22 At present it is evident that a minimum of two staff are on duty between 8.00am and 8.00pm with one staff member sleeping in at night. 24 hour cover is provided by the manager or deputy manager in her absence. The manager confirmed that there are currently three members of staff who hold the National Vocational Qualification (NVQ) level 2, or above. This represents 60 of all permanent care staff in the home. More staff are currently working towards this award. Appropriate core skills training is provided, including first aid, moving and handling, food hygiene and fire safety. This was confirmed through discussions with staff and evidenced by training records examined: ‘There are plenty of opportunities for training here’. Following discussion with the manager, it is recommended that a training matrix be developed and implemented. The provision of formal staff supervision remains unsatisfactory and following discussion with the manager it is required that formal, structured and appropriately recorded supervision for all care staff be implemented. The manager is clearly aware of the need for thorough and robust recruitment procedures, to ensure the protection of service users. Individual files that were examined, relating to recently appointed members of staff, were found to be well maintained, containing all relevant and necessary information, including two satisfactory references, proof of identity and satisfactory Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) disclosures. The Seagulls DS0000021406.V343207.R01.S.doc Version 5.2 Page 23 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 & 42 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users benefit from a competent and experienced manager. They are protected by satisfactory health and safety procedures and their best interests are safeguarded by effective quality monitoring systems. EVIDENCE: Both the manager and the deputy manager are relevantly experienced and qualified. The manager who is also joint owner of the home has worked in care for over 20 years. She demonstrated a good level of understanding of the residents needs and was able to discuss in depth residents’ current and changing care and support needs. The Seagulls DS0000021406.V343207.R01.S.doc Version 5.2 Page 24 The home has developed a system for monitoring the homes performance that includes satisfaction surveys for both residents and their families. Positive responses to the most recent survey, carried out in October 2006, indicated a high level of satisfaction with the home, the staff and the services provided: ‘I appreciate all that the staff do to ensure his well being and their support in his everyday life’. ‘I am very happy with the care and kindness that ……..receives’. The manager confirmed that the health, safety and welfare of service users and staff remain of paramount importance within the home. Since the previous inspection, as required, wooden door wedges have been removed, however it was noted that some doors including residents’ bedroom doors are still being propped open by other objects including waste paper bins. This unsatisfactory situation was discussed with the manager who is to ensure that, where necessary, automatic door closures are fitted. As previously documented, staff training is provided in many aspects of safe working practices, including moving and handling; food hygiene; fire safety and first aid. All staff training is satisfactorily recorded. COSHH assessments and guidelines are in place. Regular fire drills are undertaken and recorded. Fire alarm systems are regularly checked and records maintained. Temperature regulators are fitted to all hot water outlets, accessible to service users. All accidents, incidents and injuries are recorded and reported, as required. The Seagulls DS0000021406.V343207.R01.S.doc Version 5.2 Page 25 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 3 2 3 3 3 4 3 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 3 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 2 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 3 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 2 X The Seagulls DS0000021406.V343207.R01.S.doc Version 5.2 Page 26 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 YA36 Regulation 18 (2) Requirement Timescale for action 30/09/07 2. YA42 23(4,5) It is required that all care staff receive regular and recorded supervision at least six times a year. 30/09/07 It is required that residents’ health and safety is protected and promoted in relation to the risk of fire and that door wedges are removed from all fire doors. Advice should be sought from the fire safety officer in relation to suitable and safe alternative to door wedges. (Previous timescale of 30.01.2007 not met). The Seagulls DS0000021406.V343207.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA18 YA22 YA35 Good Practice Recommendations It is recommended that all practice guidelines be signed and dated by staff to confirm that they have read and understood the information. It is recommended that a copy of the complaints procedure be made available for the benefit of resident’s relatives and other visitors to the home. It is recommended that a staff training matrix be developed and implemented. The Seagulls DS0000021406.V343207.R01.S.doc Version 5.2 Page 28 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 The Seagulls DS0000021406.V343207.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. 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