Inspection on 20/02/07 for 2 Frederick Street

This inspection was carried out on 20th February 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

2 Frederick Street 22/02/06

2 Frederick Street 22/09/04

2 Frederick Street 12/05/04

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 08/07/2008.

CARE HOME ADULTS 18-65 2 Frederick Street Stockton-on-Tees TS18 2BF Lead Inspector Mrs Ann Ferguson Key Unannounced Inspection 20th February 2007 10:00 2 Frederick Street DS0000000037.V330837.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 2 Frederick Street DS0000000037.V330837.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. 2 Frederick Street DS0000000037.V330837.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 2 Frederick Street Address Stockton-on-Tees TS18 2BF 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) 01642 607142 01642 618518 www.reallifeoptions.org Real Life Options Miss Karen Allan Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 2 Frederick Street DS0000000037.V330837.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd February 2006 Brief Description of the Service: Number 2 Frederick Street is a modern purpose-built single storey property situated close to Stockton town centre. Accommodation is provided in three single bedrooms, none having an en-suite facility but all meeting the spatial requirements of the National Minimum Standards. Communal facilities comprise: bathroom/WC, separate WC, kitchen, lounge, dining room. Number 2 Frederick Street is registered to provide accommodation for three adults with a learning disability. The home currently charges £1,097 per person per week. 2 Frederick Street DS0000000037.V330837.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection commenced at 10am and lasted for five and a quarter hours. Three staff members were spoken to during the inspection including the manager. Two of the service users were case-tracked, looking at including individual plans of care, medication records, and personal allowance records. Three members of staff were case-tracked too. Records of staff recruitment procedures followed, staff training and supervision records were looked at. House records were examined too along with health and safety records, and policies and procedures. The pre-inspection questionnaire was received before the inspection. A tour of the home was carried out. Five comment cards were sent to relatives and professionals and three were returned. What the service does well: What has improved since the last inspection? What they could do better: Staff supervision and appraisal needs to be more regular. Some of the records need to be signed and dated, for example, within the service users’ individual files, some medication information, and the fire risk assessment. 2 Frederick Street DS0000000037.V330837.R01.S.doc Version 5.2 Page 6 A lot of quality information is collected about the home. The organisation needs to devise a formal system of collecting information from a variety of sources and reporting the findings to cover all the areas included in the National Minimum Standard. The complaints procedure for the service users needs to be updated to include the name of the local funding authority. 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. 2 Frederick Street DS0000000037.V330837.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 2 Frederick Street DS0000000037.V330837.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good An examination of the records indicates that a thorough assessment would be completed prior to admission to make sure that the prospective users’ aspirations and needs can be met. EVIDENCE: There have not been any new admissions into the home for a number of years now, however there is an admissions procedure written in August 2004, with a planned review date of August 2007. This describes a very detailed process in which Real Life Options will work with the relevant Social Services department to identify the needs of the individual. The process is service-user focused, making sure that the service user’s views are taken into account, and they can visit the home and meet staff. There is also a user-friendly policy and procedure for new admissions. Two examples of service users’ guides and contracts were examined. These had recently been reviewed and were written in an accessible format with the use of photographs and pictures. 2 Frederick Street DS0000000037.V330837.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good An examination of records indicates that service users needs and goals are reflected in an individual plan. Service users are involved in decision-making within their lives, and they take risks within their own life. EVIDENCE: Two service users’ individual Plans were examined. In each file there was a Care Plan from social services, which confirmed the suitability of the placement. One of the care plans had been recently reviewed although the other one was dated September 2005. There are a number of support plans for both the service users. These are sensitively and respectfully written. They are individualised too, and have been recently reviewed to reflect any changing needs. 2 Frederick Street DS0000000037.V330837.R01.S.doc Version 5.2 Page 10 Examples of any limitations to choice and freedom were found, and the reasons behind these decisions explained. This was to protect the health and safety of the individual concerned. The home uses a keyworker system to support the service users. Person Centred Plans have recently been drawn up for the three service users. The acting Manager organised this, involving the service users, family, advocacy, and the keyworkers. Each service user now has goals to pursue, and the manager is in the process of drawing up some monitoring charts to enable progress to be recorded. In the service users’ bedrooms examples of ‘My Life’ information was found. This described different parts of the service users’ lives, and detailed their likes and dislikes. Communication profiles were examined for two service users. These too were found to be thorough and explained clearly how to communicate with the service users. In one file the communication profile was last reviewed in July 2005 and this does need reviewing to note any changes in this area. The other communication profile examined was up to date. The home makes use of a variety of different methods of communication with the service users, including objects of reference, symbols, and picture books. Within the home, objects of reference are positioned outside each room to assist one service user with visual impairment to understand where they are going around the home. Within the individuals’ plans there are relevant risk assessments for the service users. These ensure that safeguards are put in place to enable the service users to take part in a wide range of activities. 2 Frederick Street DS0000000037.V330837.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good An examination of records and a discussion with staff indicates that the service users do take part in appropriate activities and are part of their local community. Family relationships are encouraged for service users. The rights and responsibilities of service users are recognised, and they are offered a healthy diet. EVIDENCE: None of the service users attend any adult training courses during the week. They are all based at the home and encouraged to take part in a variety of activities throughout the day. Each service user has an activity timetable kept in their bedroom, which details the range of activities they will do each week. Activities include • having a trip out • going shopping • going to the pub • hydrotherapy 2 Frederick Street DS0000000037.V330837.R01.S.doc Version 5.2 Page 12 • • • • • cleaning their bedrooms putting the rubbish out going to the pub washing the car going to the theatre. The home does try to develop people’s skills of independent living within the home, as well as providing time for personal relaxation, and making use of the community. Risks within the home are well-managed to maximise the range of activities provided, for example, the risk management plan around the use of the kitchen for a service user with visual impairment Ordinarily there are two members of staff on shift to support three service users. With the needs of the service users, this means that each person has short periods of 1:1 support throughout the day and also has time to relax themselves, bearing in mind their age and individual needs. Staff spoken to were fine with this arrangement and felt it fitted well with people’s needs. The service users all access the community at least once a day, according to the acting manager. They are well-placed for the town centre. Staff make use of any opportunity, however small, to go out with people. On the day of the inspection one service user had gone out with staff to get some more milk. One person has a very specific support plan to be followed when accessing the community. Due to a visual impairment, staff are asked to go into town a certain way and enable the service user to touch something on the way so they understand where they are, likewise on the return journey. Family links are maintained as much as possible. The home takes the service users to see their family, or they come to the house, as preferred. In addition, staff communicate by telephone to let people know what is happening and how people are. From the relatives’ comment cards, family agreed that they were always welcome to visit their family member at the home, and they were kept up to date with any important matters. They also felt that they were consulted about matters affecting their family member. The week before the inspection, the Advocacy Information Foundation had visited to assist in the drawing up of the Person Centred Plans for the services users. The support observed during the time of the inspection was respectful of the individual needs and wishes of the service users. The staff understood people’s needs and the support during the day ensured people had time to go out, to relax and to take part in household tasks. The behaviours displayed by the service users were minimised by staff who responded consistently and calmly. The service users were able to access different areas of the house as they wished. 2 Frederick Street DS0000000037.V330837.R01.S.doc Version 5.2 Page 13 The service users are involved in the preparation and delivery of a varied menu each week. They are offered choice within their meals, and get a hot meal each day. The menu is written with the service users’ known preferences in mind. The acting manager did confirm that, whilst the service users could not verbalise their dislike for something, staff did observe other non-verbal communication and respond accordingly. Typically the service users eat their meals in the dining room with staff support. Individual dietary needs are catered for. One person needs access to a lot of drinks, and that person has a small fridge in their room for this purpose. 2 Frederick Street DS0000000037.V330837.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 and 20 Quality in this outcome area is good An examination of records indicates that service users receive personal support in the way they prefer, and that their overall health needs are met. The home has a robust medication procedure that protects the service users. EVIDENCE: An examination of two service users’ files showed there to be very clear support plans, individually written. Observing the interaction between the staff and service users, the inspector felt that staff understood the individuals’ different needs and responded accordingly and respectfully. The service users’ clothes were individual to them, and they were involved in choosing what they would wear. The service users’ overall health needs are well-provided for by the home. Recently the community dentist and chiropodist had visited to see all the service users. Clear records are kept of involvement with such health professionals. 2 Frederick Street DS0000000037.V330837.R01.S.doc Version 5.2 Page 15 Within the individual files there is information for each service user sampled covering all aspects of their health, for example, mobility, sleep, behavioural and emotional needs, as well as ongoing health care. In both files there was a Health Action Plan completed in January 2007, which covered all key areas and identified responsible people. Both people had a risk assessment specifically regarding sensory impairment. One service user had a booklet called ‘My Health’ which summarised all their health results and identified areas of need. The overall list of medication, kept in the service user’s file, was found not to be dated in one file. This needs to be done to ensure that it is up to date and accurate. The medication procedure followed in the home is robust. The policy was written in August 2005, and the house procedure written in June 2006. All medication is stored in an appropriate locked cabinet. Medication is only administered by senior staff or designated responsible people. The inspector observed the medication being administered and confirmed that the procedure was followed in full. The inspector checked the medication kept for the two service users being case tracked. All amounts held were correct. The procedures for PRN medication (that is, medication administered as and when required) were very thorough too, detailing why and when it should be administered. The home has also obtain letters from the GPs stating which over the counter remedies can be bought for each service user. 2 Frederick Street DS0000000037.V330837.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 and 23 Quality in this outcome area is good An examination of records indicates that the views of service users are listened to. Service users are protected from abuse, neglect and self-harm. EVIDENCE: The home has not received any complaints since the last inspection. The complaints procedure is clearly written, and was last reviewed in June 2006. It covers all the necessary aspects and sets clear timescales for responding to complaints. There is also a user-friendly version too. In the two service user files examined there was a complaints procedure, which included photographs. This needs to be re-looked at to ensure that it includes details of the local funding authority and not just CSCI. From the relatives’ comment cards received, neither of the respondents had ever had reason to make a complaint although they indicated that they were not aware of the home’s complaints procedure. Staff have received training in abuse awareness. Six members of staff have received ‘No Secrets’ training, and abuse awareness is covered through the induction and foundation stages with new staff. There is a copy of the No Secrets file held in the office for staff to refer to. 2 Frederick Street DS0000000037.V330837.R01.S.doc Version 5.2 Page 17 Financial procedures are robust. The senior staff only have access to service users’ monies and the balances held within the home are checked and signed for daily. Currently all the service users’ monies are held with the Local Authority and the home appeals on the service users’ behalf when they need money. The service users receive all their personal allowance each week from Real Life Options. Two of the service users’ monies held within the home were checked by the inspector. Receipts were checked too. There were no discrepancies found. The home has recently succeeded in getting one of the service user’s benefits increased and backdated. 2 Frederick Street DS0000000037.V330837.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 and 30 Quality in this outcome area is good A tour of the home, and an examination of records indicates that the service users live a homely and safe environment. The home is clean and hygienic. EVIDENCE: The inspector looked around the home and observed that a very high standard of decoration is maintained. All the communal areas were personalised with photographs or pictures, or objects of reference for communication. There were no issues with the kitchen and it was in a good state of repair. In the lounge there is a gas fire without a guard. The acting manager said that the fire was not used. A risk assessment should be carried out to eliminate the need for a fire guard. The hallways are spacious. The staff would like the bathroom to be updated and have contacted the Housing Association with regards to this, although the acting manager did say that it functioned perfectly well as it was. 2 Frederick Street DS0000000037.V330837.R01.S.doc Version 5.2 Page 19 Temperatures were checked in the toilet and bathroom and did not exceed the recommended maximum temperature. The bedrooms are personalised imaginatively. Appropriate pictures have been painted on the walls in two of the service users’ bedrooms. In one room the decoration has been done to include different sensory experiences on the walls themselves The laundry area was adequate and met the required standards. The service users assist with all aspects of the laundry. Cleaning products (COSHH) were stored in a locked cupboard in the laundry. On the day of the inspection the home was found to be very clean and smelt fresh. 2 Frederick Street DS0000000037.V330837.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): 232, 34, 35 and 36 Quality in this outcome area is good An examination of records and discussion with staff indicates that staff are competent, qualified and trained to support the service users. The recruitment processes followed are robust. Staff have not all had the regular supervision they need to benefit the service users. EVIDENCE: Three staff files were examined. All of these included an induction programme that they received when they took up the post. New starters now receive a very intensive induction over two weeks to cover the mandatory training. Following this, they move on to the foundation stage, and are then registered for NVQ. One member of staff who spoke to the inspector confirmed that this structure was working in practice. The home provides training in a number of areas to ensure that staff are competent to carry out their work. Since the last inspection training provided has included: • Vulnerable adults • Fire Safety Awareness • Food Hygiene 2 Frederick Street DS0000000037.V330837.R01.S.doc Version 5.2 Page 21 • • • • • • • • • Health and Safety Values and Principles First Aid Medication No Secrets Team Teach Infection Control Safe Handling of Medication NVQ Currently 64 of staff hold and NVQ at level 2 or above, and a further 18 are registered to start in the very near future. One member of staff said that training was ‘more than adequate’. Staff could ask for training in other areas if they were unsure. In the staff files examined there was an individual training record for all staff. Available also was a monthly overview from the head office which summarised the training received by all staff and highlighted those who needed to complete refreshers. Recruitment processes followed are robust and the necessary records held in the home. Application forms and written references were available for two of the three staff sampled. In line with the organisation’s procedure, the application forms for new staff are held at head office but the required information was available. All staff had had satisfactory checks done with the Criminal Records Bureau, including a PoVA check too. Staff spoke highly of the support they received at work, and the value of supervision. One person said that supervision is ‘a time for us out of the job’. They said also ‘I have never been in a job that has had time for staff’. Another person felt that, through supervision and appraisal, ‘staff are very important’. From the staff files sampled, one member of staff had received the required number of supervisions as detailed in the National Minimum Standards. The other two staff did not have the required number of written supervision notes; one person had received three since the last inspection, the other person four. One person had received an appraisal in the last year and the other person had not. (The third staff member had not been employed long enough to require one yet). The acting manager needs to look at the issue of supervision and appraisal to ensure that staff performance is being maintained for the benefit of the service users. 2 Frederick Street DS0000000037.V330837.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 and 42 Quality in this outcome area is good An examination of records and discussion with the manager indicates that the service users benefit from a well-run home. The views of the service users are behind all the self-reviewing of the home, and their health and safety is promoted within the home. EVIDENCE: The post of Registered Manager is vacant and is being covered with an Acting Manager. CSCI is aware of this situation. An application is in the process of being submitted to CSCI to cover the role of Registered Manager. The acting manager has almost completed NVQ level 3 and intends to register for level 4 after that. The acting manager has had some management training. For example: • Absence management 2 Frederick Street DS0000000037.V330837.R01.S.doc Version 5.2 Page 23 • • • • • CSCI Medication Disciplinary and grievances Interview techniques Equal opportunities Staff spoke positively of the support they received from management, and generally how well the staff team worked together. One person said ‘We do have a good staff team’, and another person said they got lots of support from other staff. Relatives who returned comment cards said that they were satisfied overall with the care provided by the home. There are a lot of systems in place to obtain information to influence developments needed within the home. Monthly audits are carried out by the organisation, which focuses on a broad range of areas. The Quality Manager for Real Life Options was there on the day of the inspection to carry out a monthly visit. Within her role, she conducts audits over two days, which observe staff and service user interaction, activities, and paperwork. Within the organisation there is a service user forum to collect their views, although noone from Frederick Street takes part in these. Family satisfaction surveys are carried out too, and the information collated and fed back. Unfortunately no reports of the overall quality of the service provided at Frederick Street based on the views of different stakeholders were available. Team meetings are held each month. One member of staff said that typically the agenda included any new policies and procedures, memos, new training followed by service issues. Examples of these minutes were not checked. The home has completed a business plan for 2007-8. They hope to improve the garden area so that better social events can be organised to bring service users’ friends and family to the home. Also, they are planning to look into organising longer holidays for service users, and increasing the range of activities provided by the home. The home has very thorough records in place to maintain health and safety within the building. A detailed maintenance book is kept to record all maintenance issues, and recording the Housing Association’s reference number. The necessary maintenance checks and services have been carried out within the home to ensure that the home is a safe place in which to live and work. Checks carried out include: • Weekly water temperatures • Gas safety certificate • Fire alarm, lighting and extinguisher servicing • Portable appliance testing 2 Frederick Street DS0000000037.V330837.R01.S.doc Version 5.2 Page 24 • • First Aid checks Weekly vehicle checks The fire risk assessment needs to be dated and the last fire evacuation is dated as having taken place in June 2006. The Acting Manager needs to address this. Accident records are kept and filed appropriately. Head office is aware of all incidents as they occur too. 2 Frederick Street DS0000000037.V330837.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 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 3 23 3 ENVIRONMENT Standard No Score 24 4 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 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 x 3 X 2 X X 3 x 2 Frederick Street DS0000000037.V330837.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 YA24 Regulation 13 (4) Requirement The Registered Manager must ensure that a risk assessment is carried out re the need for a fire guard around the gas fire in the lounge The Registered Manager must ensure that the fire risk assessment signed, dated and reviewed. Timescale for action 30/04/07 2 YA42 13 (4) 30/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard YA2 YA19 YA22 YA36 Good Practice Recommendations The Registered Manager should locate the initial assessments for the service users prior to them moving into the home. The Registered Manager should ensure that all relevant recording sheets within the individual files are signed and dated regularly. The Registered Manager should ensure that the service users’ complaints procedure includes details of the relevant local funding authority. The Registered Manager should ensure that staff receive DS0000000037.V330837.R01.S.doc Version 5.2 Page 27 2 Frederick Street 5 YA39 written supervision and appraisal in accordance with the National Minimum Standards. The Registered Manager should ensure that service user and other stakeholders views on the running of the service are collated and available for others to read. 2 Frederick Street DS0000000037.V330837.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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 2 Frederick Street DS0000000037.V330837.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!