Inspection on 28/01/08 for Fenwick Close (3)

This is the latest available inspection report for this service, carried out on 28th January 2008.

CSCI found this care home to be providing an Good service.

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

Other inspections for this house

Fenwick Close (3) 07/02/06

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

CARE HOME ADULTS 18-65 Fenwick Close (3) Lichfield Road Sunderland SR5 2AH Lead Inspector Hilary Stewart Key Unannounced Inspection 28th January 2009 10:30 Fenwick Close (3) DS0000062832.V374077.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 Fenwick Close (3) DS0000062832.V374077.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. Fenwick Close (3) DS0000062832.V374077.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fenwick Close (3) Address Lichfield Road Sunderland SR5 2AH 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) 0191 5494358 F/P 0191 5494358 Council of City of Sunderland Mrs. Lynne Ryan Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Fenwick Close (3) DS0000062832.V374077.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd January 2007 Brief Description of the Service: Number 3 Fenwick Close is a care home, providing personal care for up to 3 people with a learning disability. Nursing care is not provided, but District Nursing services can be arranged where necessary. It is a purpose built bungalow with level access to all of the accommodation. The home is suitable for people with a physical disability or frailty. There is a large enclosed garden to the rear of the home and shared car parking to the front. The home is situated in a suburb of Sunderland, and is a bus ride or car journey away from central Sunderland. The home is near to local public transport links and local facilities, such as a doctors surgery, pubs and places of worship. The fee charged at the home is £3181.00 per person, per week. Fenwick Close (3) DS0000062832.V374077.R01.S.doc Version 5.2 Page 5 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. Before the visit: We looked at: • Information we have received since the last visit on 3rd and 15th January 2007. • How the service dealt with any complaints, concerns and safeguarding issues since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. The Visit: An unannounced visit was made on 28th January 2009. During the visit we: • • Talked with the staff a senior member of staff who deputises for the manager. Observed the people who live at the home. Talked to the people who live at the home. Due to the communication needs of some of the people it was difficult to get their opinion on the quality of care received, and therefore there are no specific comments quoted in this report. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked to see if the staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit. • • • • • We told the senior member of staff what we found. We have reviewed our practice when making requirements to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations but only when it is considered that people who use services are not being put at significant risk of harm. In future if a requirement is repeated it is likely that enforcement action will be taken. Fenwick Close (3) DS0000062832.V374077.R01.S.doc Version 5.2 Page 6 What the service does well: Each person who lives at the home had their needs assessed to make sure the home can give them the care and support they need. Information is available to help people make an informed choice about the service before they decide to use it. Each person has a care plan which contains information for staff about how to support them and meet their needs. The staff at the home treat the people as individuals and support them to live the life they choose as much as possible, so they will have new experiences and know that their opinions are valued. People who live at the home experience a variety of activities. This gives them choice, as well as building their self-esteem and confidence. The home is clean, warm and pleasantly furnished so the people who use the service have a comfortable place to live. Staff support the people to use local services so they are part of the community. Good medication systems are place to make sure that residents are not put at risk. The home has procedures for dealing with complaints so any disputes are settled quickly so good relationships are maintained. The home has protection procedures in place to protect the people who live at the home from risk of harm. Sufficient numbers of staff are in post to meet the diverse needs of the people at the home this means that staff have enough time to provide them with good care. Quality assurance systems are in place. This will help the home to shape the quality of the service and ensure it is run in the best interests of the people who use it. Fenwick Close (3) DS0000062832.V374077.R01.S.doc Version 5.2 Page 7 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. Fenwick Close (3) DS0000062832.V374077.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 Fenwick Close (3) DS0000062832.V374077.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. People are assessed before they are offered a service initially to make sure that their needs can be met at the home and also so plans can be made to make sure they get the care they need. EVIDENCE: The senior member of staff said that they were given initial information about the people when they were referred to the home. This information was provided by the staff from the resettlement team. They then carried out their own assessment of need to make sure the home could provide the care each person needed. A person can only move into the home if the manager is certain that their needs can be met there. The senior member of staff said that the key worker or themselves make arrangements for each persons assessment of need to be reviewed annually. When a person is referred to the home they can visit before they make a decision to move in permanently. The senior member of staff said that they would be gradually introduced to the other people who live there. The people, Fenwick Close (3) DS0000062832.V374077.R01.S.doc Version 5.2 Page 10 who live at the home at the present time, were gradually introduced to each other and the home. They had visits and overnight stays. Fenwick Close (3) DS0000062832.V374077.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. The standard of care planning gives a good level of information to staff to support meeting people’s needs and at the same time minimising any risk. People who use the service get the support they require and are supported to be more independent. At the same time staff make sure that their privacy, dignity and independence is respected EVIDENCE: Each person at the home has an individual care plan. The senior member of staff said that each person will have an ‘Essential Life Style Plan’. One person has one and the other are in the process of being completed. The plans are going to be used as part of the on-going assessment of the people’s needs and to plan for their future. They try to involve the people as much as possible in writing their own plan although they may not fully understand the concept due to their disability. Staff said that they use pictures and photographs to inform and involve people. Care plans included information about what care the Fenwick Close (3) DS0000062832.V374077.R01.S.doc Version 5.2 Page 12 person needed, such as how they communicate, their social relationships, things they don’t like and what type of support they need. The plans were easy to read and used photographs, however it was not clear from the care plan if this was based on a full and up to date holistic assessment of the person’s needs. Staff said that the care plans contained enough detail to give them the information they need to support the people and provide them with good care. Some people do not communicate with speech so staff said that they would make a suggestion and see how people react to get an understanding of their likes and dislikes. The senior member of staff said that they use various methods to communicate with the people at the home. They use ‘Makaton’ sign language and they observe gestures and ask people to show them what they mean. People who live at the home have communication passports which have been developed by the Local Authority’s speech and language support team. They describe how each person communicates. One person was observed interacting with a member of staff by using gesture and pointing. Some risk assessments were general and about the home as well as the person having individual ones. Records showed that the risk assessments were reviewed and up to date. The senior staff member said that they are reviewed every two months to make sure they are accurate. Staff could describe how they work consistently with the people at the home. Some individual risk assessments demonstrated that the balance of risk was too high for them to for instance have their own key to the house and their room or self medicate. The reasons for these limitations were not recorded on their care plans. The senior member of staff said that they would act on this immediately. The senior member of staff said that each person has two key workers who coordinate the care the person receives at the home. Staff said and could give examples of how they try to support people at the home to make choices. They use photographs of meals so the person can make a choice by indicating which one they would prefer. They also show them different sets of clothes for them to choose between. Staff said that house meetings are held to seek people’s views and involve them in the running of the home. Photographs and pictures are used so people can take part as much as possible. One member of staff said that they take one person clothes shopping and hold things up so they can indicate what they like. Fenwick Close (3) DS0000062832.V374077.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. The service provides healthy stimulating activities for the people at the home. Staff support them with this and in maintaining links with their family and friends. This means they can have new experiences and interests and do not become isolated. EVIDENCE: On the day of the visit the people who live at the home were taking part in a variety of activities. Two people had gone shopping and later were having lunch out. Sufficient staff were on duty to enable them to take part in activities. The activities are based upon what each person likes to do. Staff said and records showed that they are supported to go out into the community. They go to the pub for lunch and use the local shops. One member of staff said when asked what they though the home did well for the people who live there said, “We promote independence” and another said, “People have a wide variety of activities”. The people at the home did not say Fenwick Close (3) DS0000062832.V374077.R01.S.doc Version 5.2 Page 14 what they thought of their activities. Daily recordings by staff showed that people go out most days. Records showed that they have trips out to restaurants, pubs, walks and shopping. Staff said and records showed that people go swimming, trampoline, the cinema and to football matches. One person had been to a concert to see Pink Floyd. The people can choose to go on holiday on their own with staff. One person went on an individual holiday to Centre Parks. The senior member of staff said that they have tried to make sure that they have meaningful educational or work experiences but they have found that a lot of services such as colleges and work placement do not provide for people who have complex needs. People who live at the home are supported to maintain contact with their family and friends as much as possible. Staff said that they can have visitors whenever they like and records confirmed this. One person was out with their family on the day of the visit. The senior member of staff said that they have good relationships with people’s families The manager said that the meals served at the home are the choice of the people who live there. Staff said that they involve them in planning meals by using photographs of different foods. The manager and staff said that the planning of meals is flexible. The people at the home cook and prepare the meals with the staff support as much as possible. People can have drinks and snacks at any reasonable time. Adequate stocks of food and fresh fruit and vegetables were in the kitchen on the day of the visit. Fenwick Close (3) DS0000062832.V374077.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. The people at the home receive personal support when they need it so they can be as independent as possible. Some personal care plans needed more detail. Healthcare needs are generally met, which ensures that people stay healthy. Adequate medication systems are place to make sure that residents are not put at risk. EVIDENCE: The care plans identify the personal support that each person needs with everyday tasks. If they need help with their personal hygiene relevant details were in most of the care plans. However some needed more detail. In one care plan about personal hygiene it stated, “If I have missed anywhere you need to help me clean myself properly”. It did not say how many staff were needed for this task, if this was a verbal prompt or staff were to carry out the task, what equipment staff would need to use or of what gender staff needed to be. Another care play said that staff would need to support a person to have a bath but again did not say what gender of staff or if they needed to support the person with verbal of physical prompts or if staff needed to carry this task Fenwick Close (3) DS0000062832.V374077.R01.S.doc Version 5.2 Page 16 out for the person. The manager stated in the Annual quality assurance assessment (AQAA) that each person has a health care plan, which is reviewed regularly. Specialist support is available from psychologist/psychiatric services when required. The manager said that they plan to complete health action plans for all of the people in the near future. Records are in use to monitor the administration of prescribed medicines. They were up to date and had been signed by staff when they have administered medication to people. The senior member of staff said that staff have received training in the safe administration of medication. Staff do not administer medication unless they have completed this training and are competent. During the visit staff said that they had been trained and could describe the procedures that are followed in the home. There is a photograph of each person on their medication record as a safety measure for staff. The manager said that they have regular audits of medication. They keep a copy of the original prescription to check that medication delivered was correct. Storage of people’s medication was adequate. A key worker system is operated in the home; they are responsible for ensuring that the person has regular health checks. They also record any health appointments. People at the home do not control their own medication. The senior member of staff said that this decision had been made following a risk assessment. However, the reasons for this decision had not been clearly recorded in their care plan they agreed to rectify this immediately. Fenwick Close (3) DS0000062832.V374077.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. A satisfactory complaints procedure is in place. This means that complaints should be dealt with effectively so people know that their comments are taken seriously. Satisfactory protection procedures are in place to protect the people at the home from risk of harm. EVIDENCE: Policies and procedures are in place that describes how the home responds to complaints. The senior member of staff said and records showed that the home had not had any complaints since the last inspection. Anyone who moves into the home and their families receive a copy of the complaints procedure. One relative said, “Yes, I have been told about the complaints procedure”. There is a version in pictures that is easier for people to understand. Complaints forms are available at the home. Staff said they would support the people who live at the home to make a complaint. The senior member of staff said that all staff have been trained in how to protect the people at the home. There are policies and procedures on safeguarding adults to inform staff what to do if they think a person at the home could be suffering from abuse. A copy of the Local Authority’s safeguarding adult’s procedures is kept in the office. Staff and the senior could describe what actions they would take to safeguard the people who live at the home from potential abuse. One member of staff said, “Yes, we have had training”. During the visit the people at the home looked at ease and relaxed Fenwick Close (3) DS0000062832.V374077.R01.S.doc Version 5.2 Page 18 with the staff. Records showed that staff had received training in safeguarding adults. Staff were aware of the whistle blowing procedure at the home. Staff have been trained in the National Health Service ‘Control and Restraint’ method of physical intervention. The staff have refresher training every twelve to eighteen months. An appropriate record is kept of all incidents of physical interventions, which the manager checks regularly. Fenwick Close (3) DS0000062832.V374077.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 good This judgement has been made using available evidence including a visit to this service. The home is comfortable, warm and clean so the people have a pleasant place to live. EVIDENCE: The home is a purpose built bungalow and all areas are accessible to people who have a physical disability. It is comfortably furnished and the décor is up to date. There are laundry facilities that are adequate for the people living there. The bedrooms looked comfortable and the people who live at the home had personalised them. They had been made very individual. One person had saved up their own money and bought themselves a double bed. All of the rooms have their own en suite bath or shower. Fenwick Close (3) DS0000062832.V374077.R01.S.doc Version 5.2 Page 20 One communal toilet did not have disposable hand towels so this may cause a risk of cross infection. The manager wrote the following “that this toilet was used solely by one service user and it would not be appropriate to have disposable towels in this room as the service user has a history of putting things down the toilet bowl. We have considered that not having disposable towels in the room is more hygienic that having the toilet blocked with the disposable towels and there being a risk of the toilet overflowing.” The building is generally well maintained; it is clean and hygienic so the people have a pleasant comfortable place to stay in. Staff said that the housing association who own the property carry out repairs when needed. Fenwick Close (3) DS0000062832.V374077.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. Staff have opportunities for training so they know how to give the people who live at the home good care and meet their needs. The home has recruitment procedures in place, which help to prevent risk of harm to the people who live there. Not all staff records were available and some did not show that an applicants work history had been thoroughly explored during the vetting process. EVIDENCE: Staff said that they receive training, which helps them with their work. The manager said that all staff have access to training which would be specific to people who use the service. The staff said and records showed that they all have mandatory training such as first aid; food hygiene and safeguarding adults training. One member of staff said “yes we get training” and another said “yes all staff get training”. The senior member of staff said that eight staff have vocational qualifications and the others are working towards one. Sufficient staff were on duty at the time of the visit. Staff said and records showed that sufficient staff had been on duty in the home the previous week. Fenwick Close (3) DS0000062832.V374077.R01.S.doc Version 5.2 Page 22 The senior member of staff said that there had been some changes in staff due to people leaving and others taking leave. The manager stated in their AQAA that all staff have been CRB (Criminal Records Bureau) checked at an enhanced level to make sure they are suitable people to work at the home. All staff go through a recruitment process and they cannot start to work at the home until this is completed. They are interviewed and are only successful when they have two satisfactory references. Copies of staff records are kept at the Local Authority’s staffing office in Sunderland. Samples of the records were looked at and they showed that checks had been carried out. Some records, showed that gaps in some applicants work history had been explored during the recruitment process, however some others did not. It was also not clear exactly which staff worked in the home as the records in the staffing department differed to the staff list at the home. The staffing officer said that some homecare workers had been transferred to work at the home but the staffing department had not received their records yet. Fenwick Close (3) DS0000062832.V374077.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 manager has the qualifications and experience to run the home in the best interests of the people who live there. Quality assurance systems are in place. This will help the service to shape the quality of the service and ensure it is run in their best interests. The opinions of the people who live at the home are sought, about how the home is run so they know their views are valued and are used to improve the service. EVIDENCE: The manager states in their AQAA and records showed that they are qualified and have worked for several years in care homes. It was observed that there was a pleasant rapport between the people who live at the home and the staff. Fenwick Close (3) DS0000062832.V374077.R01.S.doc Version 5.2 Page 24 One member of staff said, “The manager is very approachable” and another said about the manager and senior staff, “you can go to them anytime”. The manager said that the people at the home are asked their views about the running of it as much as possible. Due to their disability we were unable to seek their views on this. Records showed that meetings take place and staff were observed talking to the people and encouraging them to make choices and decisions about what they wanted to do that day. The manager said that the home has a quality assurance system, which is still being developed. They provided the Commission with a copy of the Quality Assurance Strategy for January 2009. The manager has since stated that they use the AQAA document they said. “Information relating to what we have achieved and what we want to achieve for the following year was included in the AQAA document’”. The manager said that safety checks have been carried out on the equipment in the home; such as testing electrical equipment and the servicing the central heating boiler. Regular health and safety checks are carried out at the home. The manager said that the home has COSHH data sheets for all hazardous chemicals stored and used in the home. Fire safety risk assessments had been completed. The senior member of staff said that fire instruction takes place regularly. Staff said that they have fire drills and instruction. Records showed that regular training is provided for staff in fire safety and first aid. Fenwick Close (3) DS0000062832.V374077.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 2 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 2 3 3 X 3 X 3 X X 3 X Fenwick Close (3) DS0000062832.V374077.R01.S.doc Version 5.2 Page 26 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 YA34 Regulation 19 Requirement The registered person must have the records listed in schedule 2 for all staff who work at the home and they must make sure that a full employment history is obtained in respect of all staff candidates who will work with service users. This is to help ensure that service users are protected by a detailed recruitment process. Timescale for action 19/05/09 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 YA34 Good Practice Recommendations Personal care plans should have enough detail for staff so they exactly how they provide each person with good care. Fenwick Close (3) DS0000062832.V374077.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Fenwick Close (3) DS0000062832.V374077.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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