Inspection on 04/01/08 for 50 Belle Vue Grove

This inspection was carried out on 4th January 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

50 Belle Vue Grove 12/12/08

50 Belle Vue Grove 26/01/07

50 Belle Vue Grove 09/02/06

50 Belle Vue Grove 16/12/05

50 Belle Vue Grove 03/11/04

50 Belle Vue Grove 16/06/04

Similar services:

1 Lanark Close

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 50 Belle Vue Grove Middlesbrough TS4 2PZ Lead Inspector Brenda Grant Unannounced Inspection 4th January 2008 10:10 50 Belle Vue Grove DS0000000056.V357041.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 50 Belle Vue Grove DS0000000056.V357041.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. 50 Belle Vue Grove DS0000000056.V357041.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 50 Belle Vue Grove Address Middlesbrough TS4 2PZ 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 851160 01642 828624 H46013@mencap.org.uk Royal Mencap Society Miss Janine Louise Walker Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 50 Belle Vue Grove DS0000000056.V357041.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named individual who is above the age category is allowed to reside in the home. 26th January 2007 Date of last inspection Brief Description of the Service: 50 Belle Vue Grove is registered with the Commission for Social Care Inspection, under the Care Standards Act 2000 as a care home providing care and accommodation for up to five adults who have a learning disability. Currently there are four male residents who live there, and one bed is used for respite care. The home is part of the Mencap organisation. It is situated in a leafy residential area close to shops and a large hospital. Residents are provided with support to enable them to lead an independent lifestyle and they are encouraged to participate fully with the local community. At the time of the inspection fees ranged from £1195 to £1224. 50 Belle Vue Grove DS0000000056.V357041.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was an unannounced inspection. We assessed the information from: the Annual Quality Assurance Assessment that had been completed by the manager and we carried out a visit to the home. The visit took place over one day, five hours and fifty-five minutes in total. Discussion and observation took place with four service users, three staff, and the manager. We received surveys from: service users, staff and health and social care professionals. We looked around the home as well as examining a number of records which included those for: service users and staff files, health and safety and maintenance checks, complaints, accidents and medication. The findings from the inspection were of the manager and staff providing an excellent care service, creating a comfortable, homely atmosphere and making every effort to meet the needs of individual service users. The quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes. What the service does well: The manager and staff continued to work well, to deliver a caring and supportive service that benefits the service users who live at the home. Service users had individual and diverse needs that the home made every effort to meet. Service users enjoyed a lifestyle they chose and service users were supported in a way they preferred. The manager and staff encouraged service users to be independent and staff gave suitable support and assistance when it was needed. The home had a good working relationship with social and health care professionals, who were always available to support staff and service users at the home. Comments about the staff team, in surveys from health and social care professionals, were: “Staff perform to excellent standards and adapt accordingly to any changes needed” “There is an excellent staff team” and, “Staff communicate well with the range of health and social care professionals”. Management and staff were obviously enthusiastic with all aspects of their work and they clearly enjoyed caring and supporting the service users. One staff told us, “I couldn’t work anywhere else”. 50 Belle Vue Grove DS0000000056.V357041.R01.S.doc Version 5.2 Page 6 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. 50 Belle Vue Grove DS0000000056.V357041.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 50 Belle Vue Grove DS0000000056.V357041.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): People who use the service experience excellent quality outcomes in this area. Standard 2 Service users individual aspirations and needs are assessed before they are admitted to the home. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The manager informed us that all the service users had assessments before they were admitted to the home. Social Workers and Community Nurses completed social care and nursing assessments before the home would consider if a person was to live at 50 Belle Vue Road. The home had copies of assessment documentation that included areas of risk and if there was a need for limitations and restrictions to be placed upon the person. The Annual Quality Assurance Assessment informed us, that timetables and action plans were discussed and agreed with service users. The assessments included service user’s views, showing that service users were fully involved with the assessment process. Service users would then be clear about how care was to be delivered and service users would know of the restrictions that would placed upon them. The manager and staff told us, there were times when staff received extra training before a service user was admitted to the home. Staff would then have suitable knowledge and skills for caring for people with specific disabilities and needs. A service user confirmed, he had a full 50 Belle Vue Grove DS0000000056.V357041.R01.S.doc Version 5.2 Page 9 assessment and he told us, “I came here lots of times before I moved in”. The manager told us, most service users had many visits to the home, to make sure the home could appropriately care and support them and to make sure they were suitable for living with the existing service users. The home recorded the introductory visits and the outcomes of the visits. Information about the visits along with the assessments, were considered before a person was admitted to the home. In a survey, a Care Manager informed us, ‘The home always ensures service user’s needs are met’ and a service user wrote in a survey, ‘I was asked if I wanted to move here and I like it better than hospital’. 50 Belle Vue Grove DS0000000056.V357041.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience excellent quality outcomes in this area. Standards: 6, 7 & 9 The home has Care Plans, for each service user and the plans are regularly reviewed. Care Plans also contain Risk Assessments that include how risks are managed. Service user’s files inform how they are supported and assisted with making decisions and living their lives independently, within their capabilities. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: A sample of Care Plans was examined. Care Plans had evidence that service users were involved with and agreed with the plans. Care Plans included Risk Assessments, which gave information about how risks would be managed. Care Plans had details about each person’s care needs, how service users wanted to live their lives and their likes and dislikes. There were details about the person’s capabilities and information of any restrictions to service users. Care Plans also detailed prompts, so that staff would be aware of certain behaviours that would indicate if service users were feeling unwell. Staff told us, they explained to service users what was written so that service users fully 50 Belle Vue Grove DS0000000056.V357041.R01.S.doc Version 5.2 Page 11 understood what they were agreeing with. Risk Assessments and Care Plans were reviewed and updated monthly. Service users, Social Workers, Community Nurses, support workers and staff at the home were all involved with the reviews. A service user told us, “I have my review meetings and I say what I think about living here”. In a survey a Community Nurse informed us, ‘The home provides individualised care within agreed Care Plans’ and a member of staff wrote, ‘We treat everybody as individuals’. Staff said, they supported service users with making decisions about their lives and staff assisted service users with contacting an independent advocate, when it was needed. All of the surveys, we received from service users, confirmed service users decided what they wanted to do each day. A community nurse informed us, ‘Service users are always involved and included with decisions’. The whole aim of the service is, for service users to be independent and eventually to be able to live in the community in their own homes. In a survey a Social Worker told us, ‘The home provides a good rehabilitative service’ and ‘It is an excellent resource’. A Social Worker informed us, ‘The home promotes empowerment’. On the day of the inspection ‘site’ visit, we saw a service user being assisted with telephoning his doctor to arrange an appointment. Staff told us, service users, within their capabilities, were supported with managing their finances. Service users had ‘budget plans’, where they had their own money but there was an agreement for how much they spent each day/week. All areas of risks and restrictions were within a risk management structure, to minimise risks to an acceptable level. There was evidence that risks and restrictions were agreed with service users. In a survey a Social Worker informed us, ‘The home promotes independence while managing risk to individuals and the wider public’. All risks and restrictions were appropriately recorded and reviewed. A service user, who went shopping, knew of the procedures he needed to follow, to keep within his agreed risk management guidelines. The manager told us, this would be regularly monitored. If there were satisfactory outcomes, his guidelines may be reduced and become less rigid. 50 Belle Vue Grove DS0000000056.V357041.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience excellent quality outcomes in this area. 12, 13, 15, 16 & 17 Staff appropriately support and care for service users. Service users are offered choices of daily activities and service users can live their lives as they wish. Records did not make it clear that service users have a varied and healthy diet. Mealtimes are enjoyable. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: Staff told us, they tried to make sure service users had opportunities for personal development and they encouraged service users to be independent and maintain practical life skills. One service user spoke about the possibility of applying for a job. The manager and staff were enthusiastic about this and said they would support him with his application. Another service user told us, he was going to attend a college course, so that he could get better at reading and writing. Service users helped with daily jobs around the home and with making snacks and drinks. When we arrived, on the day of the inspection ‘site’ 50 Belle Vue Grove DS0000000056.V357041.R01.S.doc Version 5.2 Page 13 visit, a service user had decided to do some ironing, another service user was busy hoovering the stairs and a service user started painting a picture. Later that day, a service user was involved with preparing and cooking the evening meal. Staff supported service users with general daily jobs around the home and with keeping bedrooms clean and tidy. A service user told us, “I do all the jobs myself”. The Annual Quality Assurance Assessment informed us, service users were offered many choices about what they wanted to do each day and they were supported with their chosen leisure activities and with other interests and hobbies. Service user’s records included details of a planned weekly programme of activities. All routines, activities and plans were person centred, individualised and reflected the diverse needs of each person. In a survey a community nurse informed us, ‘Choices are offered within risk assessments and the Mental Health Act 1983 requirements’. A service user told us, “I go out with staff and do different activities that I like’” and in a survey a service user wrote, ‘I like the staff’. Another service user, who was about to leave the home, said, “I would like to stay here all the time”. Service users had access to local facilities of: shops, pubs, doctors, banks and churches. The manager told us, staff supported and encouraged service users to use local facilities. If service users wished to travel to the town centre, or further away from the home, they would use public transport, bus services which were available a short distance from the home. Staff said, they assisted service users to keep appropriate links with their families and friends. A service user told us, he went to see his family regularly. The manager told us, visitors were always made welcome when they came to the home. We saw there was a good relationship between staff and service users and staff spoke to service users in a respectful way. Staff told us that they respected service user’s having a right to privacy and service users could stay in their rooms or be in communal rooms, as they wished. A social worker informed us, ‘The home is excellent for privacy and dignity and staff are respectful to service users’. Service users had the right to privacy in their bedrooms and they were offered a key for the front door. A service user told us the key was, ‘So that I can let myself in’. Staff told us that service users went shopping for their own food and they were assisted with cooking their own meals. One service user proudly told us, one day he cooked breakfast for everyone, including the staff. Staff told us, “It was a lovely breakfast”. A service user told us, “I plan my menu for the week”. Staff helped service users with writing menus and they tried to encourage service users to have a healthy diet. The menus were examined, there was a record of the main meals but not for other meals. Kitchen records included: food, fridge and freezer temperatures and a cleaning rota. 50 Belle Vue Grove DS0000000056.V357041.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): People who use the service experience excellent quality outcomes in this area. Standards: 18, 19 & 20 There is satisfactory support for health and personal care and there is suitable recording of medicines. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The Annual Quality Assurance Assessment informed us, the home worked closely with social workers, community nurses and support staff, to make sure service user’s health and personal care needs were satisfactorily met. Service user’s files showed they were appropriately supported with personal and healthcare needs. The Annual Quality Assurance Assessment informed us, service user’s emotional & physical needs were recorded on Mood Charts, they assisted staff to understand how they should respond and take action to support the service users. Service users could manage their own personal care but sometimes staff needed to give prompts. Service users told us, they chose their own clothes and service user’s appearance reflected their personality. 50 Belle Vue Grove DS0000000056.V357041.R01.S.doc Version 5.2 Page 15 The home kept records of all healthcare needs in Health Action Plans that were monitored and reviewed by Community Nurses. Healthcare appointments were recorded and there was information of: the reason for the visit. the outcome and if any further action was needed. Health Action Plans were updated when necessary. There was also a record for each service user’s dental, optical and other healthcare related checks. The manager told us, when service user’s needed specialist healthcare services the home made sure appropriate referrals were made and followed through. She told us, service users specialist healthcare matters were usually addressed before service users came to live at the home. In recent months a service user was provided with equipment, to help him with his sensory loss, so that he could be as independent as possible within the home environment. We looked at recording of medicines. Medication Administration Records had signatures of the staff who had administered the medicine, to the service users, and there was a record of all medicines at the home. The manager told us, she made sure there was a weekly audit of all medicines. Staff, who administered medicines, had completed training for ‘safe handling of medicines’. There was a satisfactory lockable facility for storing medicines. The home carried out a Risk Assessment to determine if service users would be capable of looking after their own medicines. A Social Worker confirmed this and wrote, ‘Service users are individually assessed on their ability to selfmedicate’. At the time of this inspection, there was one service user who took his own medicines. 50 Belle Vue Grove DS0000000056.V357041.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): People who use the service experience good quality outcomes in this area. Standards: 22 & 23 Service users are confident their views are listened to and acted upon and they are protected from abuse, neglect and self-harm. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The home had a Complaint’s Procedure that was shared with service users, health and social care professionals and others. The procedure informed people the expected timescale when a complainant would expect to receive a response from their complaint. The manager told us, she was waiting for ‘Mencap’ to supply her with a Complaints Procedure that would be suitable for a service user who had sensory loss. Service users were regularly asked, during service user’s meetings, if they had any complaints. There had been no complaints during the last 12 months but the home had received three written and one verbal compliment. The home had Policies, Procedures and Practice Guidance, ‘No Secrets’, for safeguarding adults. Staff training information showed staff had completed training, for safeguarding vulnerable adults, but the home had made plans for staff to update their training. A member of staff said, s/he was aware of the guidelines and s/he had completed training for the protection of adults. We examined service user’s finances. There was an accurate record of all transactions, with receipts, and the home had a suitable lockable facility for monies held on behalf of service users. 50 Belle Vue Grove DS0000000056.V357041.R01.S.doc Version 5.2 Page 17 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): People who use the service experience good quality outcomes in this area. Standards: 24 & 30 The home environment is homely, comfortable and safe and repairs and maintenance work is carried out. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: Service users lived in a very homely environment. The lounges had comfortable furniture and the general appearance of the home was satisfactory. We saw that each service user’s bedroom had service user’s personal belongings and each room was differently furnished and decorated. A service user told us, his bedroom had recently been decorated in the colours and design of his choice. Service users had access to the large garage, where a ‘pool table’ was kept. One service user, who took us to see the garage, told us, “I come here and play ‘pool’ everyday, that is why I am good at it”. The home had a log of all maintenance that had taken place. We noticed there were cracks on the wall and ceiling of the first floor hallway. The manager told us, she would firstly find out why the cracks had appeared before taking action 50 Belle Vue Grove DS0000000056.V357041.R01.S.doc Version 5.2 Page 18 to redecorate the area. There was a large garden at the back of the home. The manager told us, volunteer gardeners regularly carried out work on the garden. On the day of the inspection ‘site’ visit, a group of gardeners were busy laying a path. The manager told us, there were plans to develop an area for a vegetable plot, where service users could grow their own produce. There was plenty of space for service users to move around inside the home. Service users were seen freely moving around all communal areas. The premise was clean, tidy and free from offensive odours. A Social Worker informed us in a survey, ‘The home is clean and tidy, well furnished and decorated and offers a comfortable and welcoming environment to the service users and visitors’. 50 Belle Vue Grove DS0000000056.V357041.R01.S.doc Version 5.2 Page 19 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): People who use the service experience good quality outcomes in this area. Standards: 32, 34 & 35 Service users are protected and supported by the home’s recruitment procedures and staff are appropriately trained to care for the service users at the home. Staff benefit from regular one to one supervision and annual appraisals. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: Staff files had records confirming staff had completed the required induction and basic training. The manager told us, and a member of staff confirmed, all new staff worked alongside and shadowed an experienced member of staff. There was a structured timetable all new staff completed before they worked with service users on their own. Each member of staff had their own ‘training and development plans’ that were regularly reviewed. The home had ten care staff, eight male and two female. Three care staff had achieved at least National Vocational Qualifications Level 2, in care, and one member of staff had just completed work to gain the qualification. Another member of staff was also working towards achieving the qualification. The manager informed us, she had arranged for some staff training, in the coming months, and she 50 Belle Vue Grove DS0000000056.V357041.R01.S.doc Version 5.2 Page 20 was to develop an annual training profile for all staff at the home. Staff had completed extra training so they had greater awareness and knowledge of resident’s specific individual needs. Mostly, the extra training was completed before a new service user was admitted to the home. Service users were supported and protected by the home’s recruitment policy. A sample of staff files were examined, they confirmed new staff had the appropriate Criminal Bureau checks and references before they started work. Comments about the staff team, in surveys from health and social care professionals, were: “Staff perform to excellent standards and adapt accordingly to any changes needed” “There is an excellent staff team” and, “Staff communicate well with the range of health and social care professionals”. The sample of staff records showed staff had regular one to one supervision and annual appraisals had taken place. 50 Belle Vue Grove DS0000000056.V357041.R01.S.doc Version 5.2 Page 21 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): People who use the service experience good quality outcomes in this area. Standards: 37, 39 & 42 Service users benefit from a well run home and they are included with developments and changes that take place. The health, safety and welfare of service users and staff are promoted and protected. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The manager had many years of experience of running a care home. She had completed the Registered Manager’s Award for managing a care service. Two staff we spoke with said, they were always well supported by the home’s manager. The manager carried out occasional ‘spot checks’, when she made unannounced visits to the home, to make sure everything was satisfactory. In a survey a Community Nurse commented, ‘The service has developed excellent practices and procedures in working with the service user group’ 50 Belle Vue Grove DS0000000056.V357041.R01.S.doc Version 5.2 Page 22 The home had not fully developed a quality assurance system, where service users, health and social care professionals, advocates and others were asked to give their views about the running of the home. People’s views were sought after but the feedback was not gathered together into a report and used in the home’s annual development plan. The home had regular staff and service user meetings. The meetings were an opportunity for people to comment on the running of the home. The home had carried out monitoring checks and audits of the service. A number of health and safety records were examined for: fire, portable appliance tests, water temperatures and accidents. The record of fire alarm tests showed fire alarm points were randomly tested on a regular basis and there was a record of fire drills that had taken place. Documentation confirmed there were regular monitoring checks and health and safety maintenance work was carried out. 50 Belle Vue Grove DS0000000056.V357041.R01.S.doc Version 5.2 Page 23 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 4 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 4 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 4 4 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 4 X 3 X 3 X X 3 x 50 Belle Vue Grove DS0000000056.V357041.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA17 Regulation 17 Requirement The home must have a record of all food provided for service users, so that it can be determined whether the diet is satisfactory. The cracks in the wall and ceiling of the first floor hallway must be repaired and redecorated, so that the building is kept in a good state of repair. The home must further develop a quality assurance and quality monitoring system, to gain the views of service users and other interested parties on the running of the home. Details of those views must be compiled into a report and the information should be used when the home devises the annual development plan. Timescale for action 20/02/08 2. YA24 23 30/06/08 3. YA39 24 30/06/08 50 Belle Vue Grove DS0000000056.V357041.R01.S.doc Version 5.2 Page 25 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 YA32 Good Practice Recommendations There should be 50 of care staff who have successfully achieved at least National Vocational Qualification Level 2 in care, or equivalent, so that the home can demonstrate staff are appropriately qualified. The home should have a staff training and development plan, so that there is a programme for staff’s training. 2. YA35 50 Belle Vue Grove DS0000000056.V357041.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Fourth Floor 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 50 Belle Vue Grove DS0000000056.V357041.R01.S.doc Version 5.2 Page 27 - 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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