Care Home: The Old Pepper Pot House

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What the care home does well The Old Pepper Pot House provides individualised care to meet each resident`s needs. This is achieved through thorough assessments prior to admission, detailed care plans and regular reviews of the needs of the residents. Residents and family say that the home involves them with the running of the home and decisions about residents` lives. Relatives commented that the home communicates well with them and the residents. The manager and the staff have the skills and experience needed to provide a good level of care.Residents are able to participate in community activities and are given choices about the way they live their lives. The home has a clear complaints procedure that is also available in pictorial form for residents who are unable to read. The environment at The Old Pepper Pot House is of a high standard with good quality furniture and fittings that are kept very clean and well maintained. What has improved since the last inspection? The home has an annual quality audit that involves residents, staff, relatives and professionals involved with the home. This enables them to make continual improvements that take into account the wishes of the residents. What the care home could do better: The home needs to ensure that care plans are in place when a resident moves into the home to give staff the information they need to meet the needs of residents. CARE HOME ADULTS 18-65 The Old Pepper Pot House 89 South Terrace Littlehampton West Sussex BN17 5LJ Lead Inspector David Bannier Unannounced Inspection 12 February 2008 10:30 th The Old Pepper Pot House DS0000068140.V347232.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 Old Pepper Pot House DS0000068140.V347232.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 Old Pepper Pot House DS0000068140.V347232.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Old Pepper Pot House Address 89 South Terrace Littlehampton West Sussex BN17 5LJ 01903 716477 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) Arundel Care Services Limited Mrs Janice South Care Home 6 Category(ies) of Learning disability (0) registration, with number of places The Old Pepper Pot House DS0000068140.V347232.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning disability (LD). The maximum number of service users to be accommodated is 6. Date of last inspection 13th March 2007 Brief Description of the Service: The Old Pepperpot House is a care home, which is registered to provide personal care for up to six service users in the category learning disability (LD) who are between the ages of 18 to 65 years of age. It aims to support service users to lead a stimulating lifestyle and to promote and maintain their independence. It is a mid-terrace property, which has been extended and adapted for its current use, and is located on the seafront in the town of Littlehampton. The property is a three-storey building providing private accommodation to service users in five single bedrooms located on the ground, first and second floors. There is also a basement that has been equipped and designed to provide accommodation, including a lounge, a kitchen and a bathroom to one resident. Communal accommodation is made up of two lounges and a dining room located on the ground floor. An enclosed patio garden, which is available to service users, is located to the rear of the premises. Fee levels currently range from £1150.00 to 2890.00 per week. Personal items such toiletries; chiropody and hairdressing are not included. The Old Pepper Pot House DS0000068140.V347232.R01.S.doc Version 5.2 Page 5 The registered provider of this service is Arundel Care Services Ltd. The Responsible Individual acting on behalf of the organisation is Mrs Maureen Millar and is responsible for supervising the management of the care home. Mrs Janice South is the registered manager and is responsible for the day to day running of the care home. The Old Pepper Pot House DS0000068140.V347232.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The inspection has followed the Inspecting for Better Lives methodology and is called a key inspection as it assesses those standards determined by the Commission as key standards. This inspection will also determine the frequency of inspections hereafter. The registered provider returned an Annual Quality Assessment Form (AQAA) prior to the inspection. Residents who were considered capable of completing it and their relatives were sent surveys by the Commission entitled “Have Your Say.” These are designed to enable residents, relatives and other stakeholders to give their opinions about how the care home is being run. Three surveys completed by relatives and two completed by residents were returned to us. We also received completed surveys from a health care professional and from eight staff who are employed at this care home. The information received from these documents will be referred to in this report. A visit to the care home was made on Tuesday12th February 2008. This was an unannounced inspection. However, due to the nature of residents’ disabilities we telephoned the manager so she could tell residents about our visit to reduce any disturbance to their routines. We were unable to have meaningful conversations with all the residents, however we spent time with some of them during the morning in order to form an opinion of how it is to live at the care home. We spoke to four staff on duty in order to gain a sense of how it was to work at the care home. We also viewed the accommodation and observed care practices. Some records were also examined. The visit lasted approximately six hours. Mrs South was present and kindly assisted us with our enquiries. What the service does well: The Old Pepper Pot House provides individualised care to meet each resident’s needs. This is achieved through thorough assessments prior to admission, detailed care plans and regular reviews of the needs of the residents. Residents and family say that the home involves them with the running of the home and decisions about residents’ lives. Relatives commented that the home communicates well with them and the residents. The manager and the staff have the skills and experience needed to provide a good level of care. The Old Pepper Pot House DS0000068140.V347232.R01.S.doc Version 5.2 Page 7 Residents are able to participate in community activities and are given choices about the way they live their lives. The home has a clear complaints procedure that is also available in pictorial form for residents who are unable to read. The environment at The Old Pepper Pot House is of a high standard with good quality furniture and fittings that are kept very clean and well maintained. 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. The Old Pepper Pot House DS0000068140.V347232.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 Old Pepper Pot House DS0000068140.V347232.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents’ individual needs and aspirations have been assessed. EVIDENCE: Two residents, who had been admitted since our last visit, were identified for case tracking purposes. Documents and records seen confirmed that the needs of the identified residents had been appropriately assessed. Assessments included information about each resident’s health, communication needs, behaviour, personal care needs, patterns of daily living and activities, social interaction, family involvement and financial needs. The assessment also includes an overview of the resident’s assessed needs and concludes with a judgement confirming if the care home is able to met them. The Old Pepper Pot House DS0000068140.V347232.R01.S.doc Version 5.2 Page 10 Surveys returned by residents confirmed they were asked if they wanted to move into the care home. Discussions with staff on duty confirmed they had been made fully aware of the needs of each resident and how they should be met. Information returned by the registered provider confirmed that, “Following a referral a care management assessment is requested. If the needs of the prospective resident can be met by the home then a full needs assessment is carried out by the manager and the company’s behavioural specialist within the resident’s own living environment.” The Old Pepper Pot House DS0000068140.V347232.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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ assessed needs are reflected in their individual care plan. Residents can make decisions about their lives with assistance as needed. Residents are enabled to take risks as part of an independent lifestyle. EVIDENCE: We found that there was no care plan for one resident. We discussed this with the manager who informed us that the resident had been admitted in an emergency and she had not yet drawn up the care plan. However, the manager has assured us the care plan will be in place shortly. The information provided in other care plans is comprehensive and detailed. It gave a clear diagnosis for each resident and also outlined his or her individual needs. The Old Pepper Pot House DS0000068140.V347232.R01.S.doc Version 5.2 Page 12 Staff are expected to follow guidelines, which gives them specific instructions to ensure they work in a consistent and continuous manner with residents. Care plans have been reviewed regularly to ensure they are up to date and reflect the current needs of each resident. Residents and their families are encouraged to take an active part in reviews of care plans to ensure they include each resident’s own aspirations and goals. Surveys returned by relatives confirmed that the care home does seek to consult with them about care plans. One relative commented, “The care service have met with appropriate professionals to get advice. Advice given has always been implemented after discussion with the team and the family.” Information supplied by the registered provider confirmed that, “All Residents have a plan of care which is person centred and revised regularly to reflect changes in need. Residents are involved with their care plan if able and care managers, family and other professionals input is sought if appropriate. All residents have a regular review.” Residents are encouraged to make choices on a daily basis with regard to what to eat, how to spend leisure time, when to go to bed, what to wear etc. However, in order to take account of residents’ safety and wellbeing there are occasions when choice has been limited. This includes use of approved restraint techniques, in which staff have been trained. These measures have been taken to prevent residents harming themselves and others. They are kept under constant review to ensure they are used appropriately. Written risk assessments have been kept so that residents can lead an active life which includes taking risks. During our visit we saw residents were taken out in the community accompanied by staff. Residents told us that they can make decisions about what they do each day and at the weekend. This includes visits to stay with their family where this is appropriate. Surveys returned by relatives confirmed that residents are supported in living the life they choose. One relative commented, “Carers encourage our son to participate in outdoor activities and trips – to make choice without confusing him.” Information supplied by the registered provider confirmed that, “Residents are encouraged to make choices and decisions about their own lives. Risk assessments are completed for residents and are in their care plans.” The Old Pepper Pot House DS0000068140.V347232.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, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to take part in appropriate activities. Residents have been encouraged to become part of the community. Residents have been supported in maintaining family relationships. Residents’ rights have been respected whilst ensuring their safety is maintained. Residents have been provided with a healthy, varied and appropriate diet. EVIDENCE: Each resident has an individual activity programme for each day. This includes clear information about a range of activities, including free time, in which they wish to participate. They include in house activities such as baking, individual The Old Pepper Pot House DS0000068140.V347232.R01.S.doc Version 5.2 Page 14 relaxation time and massages. Activities arranged for residents, which are located in the community include trips to shops, to local cafes and pubs. Some residents like to go for walks along the beach or to local beauty spots. One resident attends a day care facility on a regular basis. On the day of our visit we were told that one resident had gone out to Brighton for the day. Other residents were enjoying activities inside the home, including watching TV, listening to music, talking to staff and to us. We observed interactions between staff and residents were warm, friendly and appropriate. When residents’ personal care needs were attended to we saw that staff treated residents with respect and ensured their dignity was maintained. Surveys completed by relatives confirmed that residents are supported in living the life they choose. One relative commented, “My relative is unable to choose their lifestyle but makes their needs known where possible e.g. fetches their shoes for a walk. Staff appear to respond positively to these non-verbal signals and to ensure my relative is involved in activities in which they indicate pleasure.” A resident told us they like to visit their family every other weekend. They also speak to their mother on the phone regularly. Information supplied by the registered provider confirmed that, “Residents are encouraged to lead fulfilling and active lives within their limitations of ability. Staff and residents use services in the local community and the wider community for leisure and interests. One resident accesses a local church group. Staff encourage participation in all activities and household tasks such as cooking, cleaning and shopping. Where there is family involvement this is encouraged and family and friends are made welcome in the home.” The main cooked meal is provided in the evening. A snack meal such as sandwiches or soup is provided at lunchtime. Residents can sit where they wish to have their meal. Some residents use the dining room whilst others use the dining area in the kitchen. As some residents cannot tolerate the presence of others at meal times, this enables meals to be taken in a manner that suits the needs of individual residents. We saw there were sufficient staff so that they can supervise residents and provide assistance where needed. At the time of our visit, the lunchtime meal consisted of a selection of sandwiches. We were provided with copies of the menus to examine. The information provided demonstrated residents have been provided with a varied, wholesome and nutritious diet appropriate to their needs. This also includes a take away meal once a week of either fish and chips, Indian or Chinese food. Alternative meals are also provided if any resident does not want the main choice. Residents told us they liked the food provided; one resident particularly enjoys fish and chips. Information supplied by the registered provider confirmed that, “Staff cook varied and nutritious meals and service users have an input in menu planning and food shopping.” The Old Pepper Pot House DS0000068140.V347232.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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Support and personal care provided takes into account the wishes and personal preferences of each resident. The physical and emotional health care needs of residents have been met. Staff deal with medicines in a way that protects and supports residents. EVIDENCE: Guidance has been developed for each resident to ensure care plans have been implemented. This includes clear information about the manner in which each resident gets up and has care provided. It also includes detailed guidance for staff to follow to ensure challenging behaviours are dealt with appropriately. Staff are expected to follow guidelines which give specific instructions to staff to ensure they work in a consistent and continuous manner with residents. Following observations of staff interacting with residents we concluded that staff do follow them. Care plans have been The Old Pepper Pot House DS0000068140.V347232.R01.S.doc Version 5.2 Page 16 reviewed regularly to ensure they are up to date and reflect the current needs of each resident. Residents’ families are encouraged to take an active part in reviews of care plans to ensure they include each resident’s own wishes regarding how they want care and support to be provided. Records seen included a clear record of medical appointments made to health care services such as GP’s and visits made by the District Nurse. This also includes a record of the outcome of the consultation and, where necessary, the treatment to be provided. Surveys returned by relatives confirmed that the care home does meet the health care needs of residents. A survey returned by a health care professional also confirmed this. They commented, “The home’s staff took my client to the GP at my request and supported them to have the necessary investigations.” Information supplied by the registered provider confirmed, “All service users are registered with a local GP and access dentist, chiropodist, nurse psychiatrist and other health professionals as necessary.” We noted that medication has been appropriately and securely stored. Records seen had been well maintained and up to date. We were advised that only staff who have been appropriately trained are allowed to administer medication. Training records seen confirmed that staff have received in house training in the safe administration and dispensing of medication. We were informed that, currently, no resident is considered to be capable of administering his or her own medication safely. Information supplied by the registered provider confirmed that, “All staff have training in the administration of medication and complete the appropriate records. Pepperpot House has a full medication policy which staff read and sign.” The Old Pepper Pot House DS0000068140.V347232.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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has set up a system for ensuring residents’ views are listened to. Residents are protected from abuse, neglect and self harm. EVIDENCE: A complaint procedure has been drawn up so that residents’ families know how to make a complaint if they wish to do so. A procedure in picture form has also been drawn up for residents to use. This is included in the Service User’s guide. We noticed that our address is no longer the one that we use. We spoke to the manager about this who agreed to ensure the procedure is amended. Surveys returned by relatives and residents confirmed that the service has responded appropriately if concerns have been raised with them. Information supplied by the registered provider confirmed that, “ There is a clear concerns and complaints procedure in place and this is included in the Service User’s Guide and made available in the home for all service users’ families and staff.” It was also confirmed that this service has received no complaints in the last 12 months. Staff on duty confirmed they know how to identify different types of abuse and also know what to do if they witness a resident being abused. Training records confirmed that staff are provided with training about adult protection. The registered provider has also provided information that confirms appropriate The Old Pepper Pot House DS0000068140.V347232.R01.S.doc Version 5.2 Page 18 policies and procedures are in place that are designed to protect vulnerable adults from harm. The registered provider has confirmed that, “All staff have a full induction which includes policies covering concerns, complaints and protection. All staff have a Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) check and are given in training in POVA (identifying and reporting abuse).” The Old Pepper Pot House DS0000068140.V347232.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 and 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents have been provided with a homely, comfortable and safe environment in which to live. The premises has been decorated, maintained and furnished to a high standard. The home has been kept to a high standard of cleanliness and hygiene. EVIDENCE: We visited the private accommodation of each resident, the lounge and the dining room. Those areas of the home seen were presented in a homely and comfortable manner. The decoration and furnishings provided to a high standard and ensured residents live in a comfortable and safe environment. We also noted that many of the rooms are spacious and those to front of the building provide attractive views out to the seafront. Residents have been able to personalise their own rooms. Colour schemes and soft furnishings have The Old Pepper Pot House DS0000068140.V347232.R01.S.doc Version 5.2 Page 20 been chosen which reflect the personality and interests of each resident. Other items bought on behalf of residents include posters and pictures, televisions, CD players, and sensory equipment. Comments made by relatives and residents in surveys were positive and confirmed the environment is always kept fresh and clean. We also visited bathrooms, toilets, the kitchen and the utility room. These areas of the premises were fresh, very clean and hygienic. Cleaning schedules are in place to ensure all areas are cleaned on a regular basis to ensure hygiene is maintained to a high standard. Information supplied by the registered manager prior to this visit confirmed the registered provider has also taken appropriate steps to ensure the premises and equipment within the care home is safe for use. Gas and electrical appliances have been checked and maintained regularly. There is an internal system for staff to use to record and report any issues related to the maintenance of the premises to ensure any defects or repairs are dealt with efficiently. The manager commented, “Old Pepperpot House has large, airy, bright well decorated rooms throughout, residents’ rooms are large and to a high standard. All decoration and furnishings are to a high standard. ” The Old Pepper Pot House DS0000068140.V347232.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, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Competent and qualified staff support residents. The home’s recruitment practices and procedures protect vulnerable residents. The staff team have met residents’ needs. EVIDENCE: We examined the recruitment records of two staff that had been appointed since our last visit. We found that all appropriate information and checks were in place to ensure vulnerable residents have been protected. This included two written references, proof of identity and criminal record checks (CRB). Surveys returned by residents and their relatives confirmed they were satisfied with the care provided. Residents told us that the staff treat them very well. Residents also told us that staff do listen to and act on what they say. Information supplied by the registered provider confirmed that, “The company follows a specific recruitment policy and the interview process is standardised.” The Old Pepper Pot House DS0000068140.V347232.R01.S.doc Version 5.2 Page 22 We looked at staff training records. They demonstrated that newly appointed staff undertake structured induction training. This includes providing an understanding of the principles of good care practices and covers the promoting of residents’ rights, independence, choice and dignity. Induction training also includes providing a basic understanding of how to work with people who have learning disabilities. Training records also provided evidence that confirmed staff have been provided with mandatory training such as identifying and reporting abuse, fire safety, health and safety, first aid, infection control and food hygiene. Staff spoken to confirmed the training and induction training they had received. They also confirmed that they had received training in understanding autism, understanding epilepsy, working with people who have challenging behaviours, and approved restraint techniques. Surveys completed by relatives confirmed that staff have the right skills and experience to support residents and provide for individual needs. There was also evidence that demonstrated they receive regular support and supervision from a senior member of staff. Staff also told us they found the management does provide staff with the support they need. Information supplied by the registered provider confirmed that, “More than 50 of staff have the National Vocational Qualification (NVQ) in care at level 2 or above. The company has a full training programme. All staff are given supervision every eight weeks which includes training needs identified and an appraisal each year.” The Old Pepper Pot House DS0000068140.V347232.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 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care home is well run and in a way which benefits residents. The views of residents and their families are sought as part of any self – monitoring, review and development of the care home. The health, safety and welfare of residents and staff have been promoted. EVIDENCE: Mrs Janice South has been registered as the manager of this care home since our last visit. As a result of the registration process she has demonstrated she has the necessary skills, knowledge and experience to manage the service. The Old Pepper Pot House DS0000068140.V347232.R01.S.doc Version 5.2 Page 24 Representatives of the registered provider visit Old Pepperpot House each month to ensure this care home is being run in the best interests of residents. Reports of such visits were available for the inspector to examine. Reports include details of discussions with staff on duty and, where possible, discussions with residents or observations of care and support provided. The registered manager meets regularly with her staff team to discuss issues related to the service provided and the individual care needs of residents. This ensures the staff team are clear about what is expected of them and are aware of how the aims and objectives of the service should be implemented. We saw evidence that questionnaires, which include sections entitled About the Home, About Care in the Home, About Life in the Home and Staff Attitude have been sent to residents, their relatives and to staff. The results of the last survey undertaken were also seen. The registered provider has compiled a list out of the results that identifies the key areas that need to be reviewed, and the date of any action taken to make improvements to the service as necessary. Information supplied by the registered provider confirmed that, “Once a year we send out Quality Assurance questionnaires to service users, relatives, care managers and advocates.” Surveys completed by residents and relatives confirmed residents felt well cared for. One relative who completed a survey commented that this care home provides, “Good care and a wonderful environment.” When considering what the care home does well, another relative commented, “Communicate – The directors and staff at Old Pepperpot keep in close contact with me and discuss any issues that arise.” A third relative commented, “My husband and I were very impressed with the staff management style. Both the manager and deputy manager take their turn at cooking meals. All the staff we met seemed to have a genuine affection for my relative and treated her with respect.” Information supplied by the registered manager prior to this visit confirmed the registered provider has also taken appropriate steps to ensure the premises and equipment within the care home is safe for use. Gas and electrical appliances have been checked and maintained regularly. There is an internal system for staff to use to record and report any issues related to the maintenance of the premises to ensure any defects or repairs are dealt with. Training records seen confirmed that staff have been provided with training regarding health and safety issues, fire prevention, manual handling and food hygiene. This will ensure the safety and wellbeing of residents and staff. The Old Pepper Pot House DS0000068140.V347232.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 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 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 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 The Old Pepper Pot House DS0000068140.V347232.R01.S.doc Version 5.2 Page 26 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 The Old Pepper Pot House DS0000068140.V347232.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone 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 Old Pepper Pot House DS0000068140.V347232.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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