Inspection on 19/09/07 for The Summers

This inspection was carried out on 19th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Summers 27/09/08

The Summers 23/08/06

The Summers 23/11/05

The Summers 09/06/05

The Summers 30/09/04

The Summers 15/06/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Sutton Lodge Nursing Home

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

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

CARE HOME ADULTS 18-65 The Summers The Summers Yeend Close West Molesey Surrey KT8 2NA Lead Inspector Lisa Johnson Unannounced Inspection 19 September 2007 09:20 th The Summers DS0000060466.V346424.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 Summers DS0000060466.V346424.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 Summers DS0000060466.V346424.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Summers Address The Summers Yeend Close West Molesey Surrey KT8 2NA 020 8979 4689 020 8941 0468 hannah.thorogood@surreycc.gov.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) Kingston & Wimbledon YMCA Hannah Thorogood Care Home 28 Category(ies) of Dementia (0), Learning disability (0), Mental registration, with number disorder, excluding learning disability or of places dementia (0), Physical disability (0), Physical disability over 65 years of age (0) The Summers DS0000060466.V346424.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Physical disability - (PD) Physical disability, over 65 years of age - (PD(E)) - 5 Learning disability - (LD) - 4 Mental disorder, excluding learning disability or dementia - (MD) - 1 2. Dementia - (DE) - 1 The maximum number of service users to be accommodated is 28. Date of last inspection 23rd August 2006 Brief Description of the Service: The Summers is a large purpose built detached property located near the town centre of West Molesey, Surrey. The service provides a good standard of accommodation and facilities for up to 28 adults with physical disability, some over 65 years and a maximum of 5 service users with learning disabilities. All current bedrooms are single and are set across two floors. The home has a private garden and parking for several cars at the front. Kingston and Wimbledon YMCA own the service and staff are employed by Surrey Social Services. The weekly fee is £1,051.88 The Summers DS0000060466.V346424.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was part of a key inspection. The site visit was unannounced and took place over nine and half-hours commencing at nine twenty am and finished at six thirty pm. Mrs. L Johnson Regulation Inspector carried out the visit. During this visit inspector spoke to six people who live in the service to gain their views on the care provided. Twelve surveys were received from people living in the service twelve from relatives and two surveys were received from health care professionals. These comments are reflected throughout this report. A full tour of the premises took place. Information was supplied in the Annual Quality Assurance Assessment (AQAA) provided by the registered manager. Care plans, staff training records, staff files and policies and Procedures were sampled. The inspector also spoke to five members of staff. The inspector would like to thank the people living in the service and staff for their time, assistance and hospitality during this visit. What the service does well: During this visit the home was observed to be friendly and welcoming. The home provides a spacious environment and equipment which meets the needs of people using the service and a relative commented, “The facility provides my relative with modern facilities and his room his fitted with the necessary equipment to aid him” and another relative commented, “ good, well presented building which is clean and tidy”. The home is cleaned to a good standard and was hygienic and positive comments were received about the facilities provided by the service which included “the laundry department is very good” and another relative commented, the laundry person takes pride in her work”. A number of positive comments were received from people using the service and their relatives about the care provided including, “ I am happy here”;” I visit the service for respite and feel the Summers is my second home”: “The Summers has friendly carers and my relative enjoys his visits” and my relative always appears happy and relaxed when we visit”. The Summers DS0000060466.V346424.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home must formulate a pre- admission assessment, which is to be conducted prior to any future individuals moving into the service. The service has made progress in introducing more detailed life care plans but these must be completed for all individuals using the service. Care plans must be reviewed on a regular basis ensuring that any changes in need are identified, Care plans must be signed by people living in the service and or their representatives ensuring their agreement to their care plan and daily records must be recorded to reflect each individuals identified goals. Medication that is transcribed by staff on to the medication administration record must be checked and signed by two members of staff ensuring the safety and well being of people using the service. It is recommended that the up to date complaints procedure is made available to relatives or representatives. A number of concerns have been raised by people using the service and their relatives about the current staffing arrangements in the home with the high use of agency. It is required that the home must ensure that enough suitably experienced staff are provided to meet the needs of people ensuring their health, welfare and safety. Two written references must be made available for viewing on staff personal files. The registered manager must complete management training and quality assurance surveys must be conducted to gain feedback from people and their representatives ensuring that the home is run in their best interests. During this visit it was observed that the service does not maintain written records confirming that water temperature checks are conducted on a regular The Summers DS0000060466.V346424.R01.S.doc Version 5.2 Page 7 basis, therefore this was made an immediate requirement that this matter is attended to. 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 Summers DS0000060466.V346424.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 Summers DS0000060466.V346424.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that prospective people moving into the service will have the information they require to make an informed choice about where to live. The home needs to develop a pre- admission assessment, which should be completed prior to any individual moves into the service. EVIDENCE: Since the previous visit the statement of purpose and service user guide have been amended and this document was available in draft form. The manager is advised that that this document is issued to individuals currently living in the service ensuring that they have up to date information. The service has an admission procedure and this process was included in the service user guide. The current registered provider is seeking to sell their services; therefore the home is not receiving any new admissions for the time being. During discussions with the manager there was no evidence available to confirm that pre- admission assessments had been conducted for current individuals living in the service, therefore it is required that a pre- admission assessment be conducted for all future referrals. The Summers DS0000060466.V346424.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 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is making progress to ensure that people living in the service are provided with an updated care plan, which records their individual needs and goals. People using the service are supported to make decisions about their lives with assistance and they are supported to take risks as part of an independent lifestyle. EVIDENCE: Information supplied with AQAA states that all people living in the service are provided with an individual care plan. Since the previous visit new life/care plans have been introduced. Two plans were sampled which were person centred in approach and were detailed and comprehensive and covered areas such as personal, health, mobility, communication, social, leisure and religious needs. However another care plan sampled had not been updated and it was required that this be completed. Further improvement must be made in ensuring that all care plans are reviewed on a regular basis, as there was no evidence recorded to indicate that this was happening. This is to ensure that the care plan reflects any changing needs. Two people spoken with during this visit said that staff discuss their plan with them, although it is required that The Summers DS0000060466.V346424.R01.S.doc Version 5.2 Page 11 people using the service and or their representatives sign their plan to ensure their agreement. It is also required that daily care notes must reflect the identified goals recorded in the care plan. An agency member of staff stated that the care needs of individuals are discussed with them The service holds regular flat meetings to provide people with the opportunity to raise issues and make decisions and choices about their daily lives. People are provided with opportunities with support to organise holidays of their choice. One person has expressed a desire to move on to a different care provision, which is being supported by the service. People using the service are provided with the opportunity to be involved in the recruitment and selection of staff and one individual has been appointed as a spokesperson representing the home who will be attending meetings with both Surrey County Council and Kingston and Wimbledon YMCA about the future of the home and proposed provider. Ten out of twelve people surveyed said that they are able to make decisions about their daily lives Identified risks are recorded in the care plan, which were comprehensive and covered all aspects of care. Risk plans viewed during this visit covered areas for example such as mobility, prevention of falls, use of the hoist and medication, although these must be reviewed regularly. The Summers DS0000060466.V346424.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, 15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the service are provided with a range of appropriate activities and engage in a range of leisure activities and they are supported to take part in the local community. The rights and responsibilities of people are respected and they are provided with a well-balanced and nutritious diet. EVIDENCE: A number of individuals go out on a daily basis by attending day services and clubs. Activity plans have been reviewed and the home is currently gaining views from each individual by supporting them to make choices about their preferred activities. Another person told the inspector that he now attends a gym, which he is enjoying. The home in repose to feedback from people using the service have ensured that more activities have been provided which has included shopping excursions and visits to places of interest. One person told the inspector that, “Bingo is arranged on Monday nights and an exercise group is held on Fridays”. The home has purchased a karaoke machine and regular party nights have been held and baking sessions with the home The Summers DS0000060466.V346424.R01.S.doc Version 5.2 Page 13 wishing to increase the opportunities for people to be involved more daily living skills. The home also plans to support people to attend hydrotherapy. People living in the service maintain links with their family and friends. During this visit one individual was visited by their relative. People spoken with during this visit said that they are able visit in private. One individual has a telephone in his room to maintain contact with their family. Payphones are available in each flat. Another individual spoken with told the inspector that she has a boyfriend and that staff respect her right to have privacy. During this visit staff were observed to knock on peoples doors before entering and they are provided with a key if they wish to use this. During this visit people were observed to have unrestricted access and positive interaction was observed between people using the service and staff. A relative surveyed commented, “ It is a comfortable home with caring staff”. People using the service are supported to make preferences about their meals. Meals are chosen a week ahead and choices are provided. A cook is employed by the home and meals are served in the dining room of each flat. One individual said that they are vegetarian and her preference to have this diet is respected and accommodated. The manager said that the dietician has reviewed the menus. Four people spoken with said that they were satisfied with the meals provided and one person surveyed said, “the food is good and well presented”, The Summers DS0000060466.V346424.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 & 20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that people receive personal support in the way they prefer and in the main their physical and health needs are met, although some matters need further improvement to ensure this is fully met. People are in the main protected by the homes medication administration procedures with one matter identified needing improvement. EVIDENCE: The personal and health care needs of people were recorded in their life plan, which were sampled for two individuals. The personal and health needs were recorded in detail and included information such as assistance required with eating and drinking, moving and transfer. Another person requires fluid intake monitoring, which was supported by the completion of fluid intake charts. Improvement is needed in carrying out regular reviews ensuring that any identified change in needs is recorded. It is recommended that plans would benefit by including details of the preferred routines such as times getting up for each individual which would assist new staff to meet peoples needs. Surveys were received from two health care professionals who say that the home works in partnership with them and incorporates specialist advice into the care plan. One person spoken with during this visit said, “ I am happy here, I feel well looked after” and one relative survey stated, Clients are The Summers DS0000060466.V346424.R01.S.doc Version 5.2 Page 15 always clean and tidy and those who need help to eat and drink are always given it”. Out of twelve relatives surveyed five say that the home meets the needs of their relative, seven say usually and two say sometimes and further comments included, “ health care needs are met when the correct staff are on duty” and another person stated that they have had to bring health care matters to the attention of staff. The inspector had the opportunity to speak to another health care professional who was attending the home who expressed some concerns about the change in staff and that that were some inconsistencies with some people not aware of instructions. This matter was bought to the attention of the manager during this visit. Since the previous visit the homes medication administration procedure has been reviewed. A list was maintained of all staff trained and authorized to administer medication. The home has changed its pharmacy and staff have staff have received training Medication was stored appropriately and records are maintained of medication received and disposed of. Medication administration records were sampled. Two gaps were noticed where medication had not been signed for, although these had been highlighted and an auditing system is in place. It was observed one medication administration card had been completed by a member of staff but had not been checked and signed by a second person, therefore it was requirement that where any medication is hand transcribed by staff this should be checked and signed by two members of staff ensuring the health, wellbeing and safety of people using the service. One person has chosen to self medicate and a risk assessment was in place. The Summers DS0000060466.V346424.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 &23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that the views of service users are listened to and acted upon although improvement is needed in ensuring that relatives are provided with the information they require should they wish to raise a concern. The home is able to demonstrate that it responds to safeguarding adults from abuse procedures ensuring that people using the service the protection of from abuse. EVIDENCE: The service has a complaints procedure in place, which is also included in the service users guide. The Commission has received no complaints. The home has received one complaint, although some matters have been referred under the local authority safeguarding adult’s procedures. Ten out of twelve people surveyed say that they know how to make a complaint. Five people say that the home acts and what they say and seven say usually. Two people with during this visit said that any concerns raised are responded to. Six relatives surveyed said they knew how to make a complaint, two said that they had forgotten and two responded no. One person commented that, “there has been lack of communication with dealing with certain issues within the system” and another relative stated, “requests and concerns are usually noted but the response is not as fast as it could be”. It is advised that all relatives/ representatives are made aware of the up to date complaints procedure. The The Summers DS0000060466.V346424.R01.S.doc Version 5.2 Page 17 inspector received a number of concerns both during this visit and from surveys about staffing arrangements in the home. Since the previous visit a number of matters have been referred and investigated through the Surrey Multi- agency safeguarding adults from abuse procedure. The manager stated that all staff has undergone up to date training in this matter, although staff training records could not be accessed to verify this, therefore it was required that this information be provided to the Commission. During discussion with the manager the service is demonstrating that people using the service are being enabled to speak out against poor practices and staff are being made aware of their responsibilities. The home has safeguarding adults from abuse and whistle blowing policy and a copy of the Surrey multi- agency safeguarding adults from abuse procedure was available. Three members of staff spoken with during this visit were clear about their responsibilities and the action that would take should they ever witness any abuse. Ten out of twelve people surveyed said that staff treat them well and two people answered usually with one person commenting that temporary staff do not always understand their needs. Four people spoken with during this visit said that staff were kind but raised concerns about the present staffing arrangements and the use of agency staff. A relative had raised an area of concern, which was bought to the attention of the manager, which they were already aware of and had taken appropriate action. The Summers DS0000060466.V346424.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, 25, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the service have a well-maintained, comfortable, homely and safe environment, which is clean and hygienic. EVIDENCE: The building is purpose built and is divided up into four flats. During this visit the home was generally maintained, although a door requires replacement in one bathroom, as it was broken Two assisted bathrooms required repair, which have been reported. The manager stated that there is a refurbishment plan in place and Information supplied with the AQQA stated that over the next year there are plans to install a wet room is to be provided for people who wish to have a shower instead of a bath The building is spacious accommodating people who use wheelchairs, entrances and doorways, which are accessible, and hoist-tracking equipment is provided in bathrooms and bedrooms. A relative stated, “the facility provides my relative with modern facilities and his room his fitted with the necessary equipment to aid him”. The Summers DS0000060466.V346424.R01.S.doc Version 5.2 Page 19 Bedrooms viewed during this visit were comfortable and well furnished with appropriate beds provided to meet the needs of people. The bedrooms were also personalised and homely reflecting peoples individual tastes and preferences. There was pleasant, well maintained accessible garden. During this visit the home was cleaned to a good standard and was hygienic Cleaning schedules were in place. Ten out of twelve people surveyed said that the home is always clean and fresh The home provides an infection control policy and staff attend relevant training. Separate laundry facilities are available which were maintained to a good standard. A relative surveyed, said, “the laundry department is very good” and another relative commented, the laundry person takes pride in her work”. The Summers DS0000060466.V346424.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, 33, 34 & 35 Quality in this outcome area is Poor. This judgement has been made using available evidence including a visit to this service. The home needs to continuously monitor the staffing arrangements in the home ensuring that the health, welfare and safety of people using the service is protected. Staff are trained to support the needs of people living in the service. Improvement is needed to ensure that people living in the service are protected by the homes recruitment policy and practices. EVIDENCE: There have been a number of staffing matters that have resulted in less permanent staff being employed in the service. During this visit there was eight members of staff on duty plus a team leader. The staff team was a mixture of agency and permanent staff. The inspector was informed that regular staff are requested from an agency some of which have worked in the home two to three years. Where possible a permanent member of staff is on duty with an agency member of staff, however this cannot always be accommodated. Due to Kingston and Wimbledon YMCA selling their services there are to be no further admissions to the service until the new provider has been identified. Staff are contracted by Surrey social services and a decision has been made to cease any further staff recruitment. The inspector was informed that the home uses a regular agency and where a possible they request staff that have worked in the home regularly and who know the people The Summers DS0000060466.V346424.R01.S.doc Version 5.2 Page 21 living in the home well. However a number of people, and relatives surveyed raised concerns about the staffing arrangements, including “Most new agency staff do not understand my needs and we need to have permanent staff”;” the usual staff have the right skills but some of the agency staff lack experience; “”agency staff need more training” and a comment received from a health care professional stated, “there is poor staff morale and increased agency staff”. During this visit three people who live in the home were concerned about the changes in staff. Three members of staff spoken with stated that it is difficult at times when new agency staff come to the home. Other comments on this matter have also been reflected in other areas of this report therefore it is required that this matter is monitored closely ensuring that the staffing skill mix is appropriate to meet the needs of people using the service. Since the previous visit the staffing at levels have been increased to three, which includes a senior carer. The home also employs ancillary staff catering, laundry and administrative staff. Information supplied with the AQAA states that a number of staff hold National Vocational Qualifications (level 2) or above and four members of staff are working towards the qualification. Staff have undertaken a range of training including safeguarding adults from abuse, moving and handling, safe food handling, infection control and medication administration. One member of staff spoken with stated that she had received a lot of training including equality and diversity. New staff receive induction based on the Skills for care common induction standards. Another member of staff stated that she had been provided with a copy of the General Social Care Code of conduct. However during this visit the staff-training schedule couldn’t be accessed and it is required that this information be provided to the inspector to verify the training completed by staff. The staff group are mixed ethnicity with the majority of staff being female. Recruitment is based on an equal opportunities policy. During this visit the recruitment files were sampled for two members of staff. All the required information was available except there were no evidence of two written references for either of these individuals, therefore it was required that this matter be attended to ensuring he welfare and safety of people using the service The Summers DS0000060466.V346424.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 & 42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Improvement is needed in ensuring that the manager has obtained an appropriate management qualification. Further improvement is needed in ensuring that the home is run in the best interest of people using the service and their health, safety is mainly protected with one issue needing attention. EVIDENCE: Since the previous visit the manager has registered with the commission, although it is required that she completes the Registered Managers Award. A second manager has also been appointed who has past experience working in social care and holds National Vocational Qualifications. Staff spoken with said that they felt supported by the management structure and staff meetings are conducted, although some staff thought they would like more communication with the managers in light of the pending change of providers. Information supplied with the AQAA and from discussion with the manager there was an The Summers DS0000060466.V346424.R01.S.doc Version 5.2 Page 23 open approach about areas of the service that need improvement which have been identified with progress being made to achieve this During this visit the manager on duty was observed to be approachable and accessible to people living in the service who made time to speak to individuals privately. The service holds regular flat meetings ensuring the views of people are held. One person living in the service has been appointed as a spokesperson representing the home that will be attending meetings with both Surrey County Council and Kingston and Wimbledon YMCA about the future of the home and proposed provider. The responsible individual conducts monthly quality visits, which were maintained in the service, which were detailed, Further work needs to be conducted in ensuring that Quality assurance surveys are conducted for individuals living in the service and their representative. Information provided with the AQAA indicates that a number of policies and procedures have been reviewed and introduced and some of these were sampled during this visit. The manager stated that these are bought to the attention of staff. During a tour of the premises substances hazardous to health (COSHH) were stored securely and appropriately. Fire records were appropriately maintained. Information provided with the AQAA identified systems are in place for routine service and maintenance arrangements for the environment. although it was observed that written records were not maintained confirming that water temperature checks are conducted. Therefore it was immediately required that this matter be attended to ensuring the health, welfare and safety of people using the service. The Summers DS0000060466.V346424.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 X 29 3 30 X STAFFING Standard No Score 31 X 32 3 33 1 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 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 2 3 2 X 2 X 2 X X 2 X The Summers DS0000060466.V346424.R01.S.doc Version 5.2 Page 25 Yes 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 YA2 Regulation 14(!)(a-d) Requirement The manager must ensure that the homes policies for the introduction of all potential service users are fully robust, and meet the needs of the service and the service users. a) All people using the service must have a completed care plan in place and daily records must make reference to individuals identified goals b) Care plans must be reviewed regularly and evidence of this must be provided. (Previous requirement 30/10/06 not met). c) Care plans must be signed by people using the service and or their representatives to confirm their agreement to their care plan 4 5 YA32 YA33 18(1)(a) A copy of the homes stafftraining schedule must be provided to the Commission. 18(1)(a)(b) The manager must ensure that appropriately trained and DS0000060466.V346424.R01.S.doc Timescale for action 19/12/07 2 YA6 15(1)(2) (b) 19/12/07 10/10/07 20/10/07 The Summers Version 5.2 Page 26 6 YA34 19(1-5) Schedule2 experienced staff are provided on duty at all times emphasising the measures employed to ensure the continuing safety and security of the service users. (Previous requirement 30/10/06 not met) Two written references must be 26/09/07 acquired before any member of staff commences employment in the home The registered manager must 19/12/07 make arrangements to commence the Registered Managers Award qualification Quality assurance surveys must 19/01/08 be conducted to gain feedback from people using the service and their representatives Written records must be 19/09/07 maintain to verify that the water temperatures are checked on a regular basis 7 YA37 9(2)(b)(1) 8 YA39 24(1) 9 YA42 13(4) (b) (C) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA18 Good Practice Recommendations It is recommended that care plans include detail about individuals preferred routines ensuring that staff have the information that they require to meet individuals preferences It is recommended that the homes complaints procedure is made available to relatives. 2 YA22 The Summers DS0000060466.V346424.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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. 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