Inspection on 03/04/07 for All Saints Vicarage

This inspection was carried out on 3rd April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

All Saints Vicarage 18/11/05

All Saints Vicarage 19/08/05

All Saints Vicarage 04/02/05

All Saints Vicarage 10/08/04

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 All Saints Vicarage Church Road Eppleton Hetton-le-hole Tyne And Wear DH5 9AJ Lead Inspector Mrs Elsie Allnutt Key Unannounced Inspection 3rd April 2007 10:00 All Saints Vicarage DS0000015776.V333296.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 All Saints Vicarage DS0000015776.V333296.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. All Saints Vicarage DS0000015776.V333296.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service All Saints Vicarage Address Church Road Eppleton Hetton-le-hole Tyne And Wear DH5 9AJ 0191 526 6326 P/F 0191 526 6326 sandra.douthwaite@autismnorth.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Autism North Limited Miss Sandra Douthwaite Care Home 6 Category(ies) of Learning disability (6) registration, with number of places All Saints Vicarage DS0000015776.V333296.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th November 2005 Brief Description of the Service: As the name suggests the house was previously a vicarage. It is a big old building in its own grounds with an extensive grassed area and mature trees. The home has recently been extended to the back of the building but a large garden area still remains. The building is next door to the church it used to belong to. On the other side is a childrens play area. Church Road is a quiet street that runs parallel to the main road through Hetton. The interior of the house retains many of its original characteristics, such as wooden shutters on the windows and care has been taken during the extension work to maintain such features. The décor is bright and the furniture uncluttered, allowing freedom of movement. All of the service users have single bedrooms that are individually decorated. The extensive grounds are kept tidy by a gardener and the general repairs are addressed by a handyperson. The home is currently registered to provide care for six service users under 65 years all of whom have a learning disability and who have autism. Prior to August 2006 this service was registered for one person under 18 years, this part of the registration has now been removed as all service users are now 18 years or over. It is the aim of the home to develop activities, including daily life skills that are designed to reduce anxiety while creating personal security for the individual. The service has developed a Service User Guide that is in picture format. This informs service users and other interested parties about the service. There is also a copy of the most recent inspection report in the home. The range of fees charged by the home is not available. All Saints Vicarage DS0000015776.V333296.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took 7.5 hours over one day in April 2007. Information about the service was gathered in a number of different ways. The views of five service users and five members of staff were sought as was the views of a visiting community nurse. Surveys sent out prior to the inspection were received from relatives of the service users. Due to the needs of the service users, their satisfaction of the service provided did not rely on verbal communication but it was interpreted through observations of body language, interaction with staff, discussions with staff and the examination of records. This process demonstrated that all were satisfied with the service and the care and support given by staff. A sample of service users’ care files and the homes records were examined. Health and safety issues were looked at during a walk around the building. What the service does well: This service provides accommodation of a good standard. It is well maintained and as a result of effective cleaning routines provides service users with a clean and hygienic place in which to live. The friendly interaction between service users and staff creates a warm and welcoming atmosphere. So that new service users are supported well and in an appropriate way, staff work closely with other professional people who are involved in the individual’s care. This means that staff can seek advice from people who know the person well and learn from their experience and expertise. Service users’ are supported to live a full and active lifestyle and as a result they take part in a variety of different activities both in their own activity centre and the local community. Some of the staff have worked at the home for many years and as a result, positive relationships have developed with the service users. The staff follow detailed care plans which means that service user’s complex needs are met in a consistent way. Staff work with respect and skill and aim to involve service users in making choices about what they prefer to do. A mutual respect was observed between staff and service users. Comments from relatives about staff include “ The staff are dedicated and friendly.” “Staff really put themselves out for the benefit of the service users.” All Saints Vicarage DS0000015776.V333296.R01.S.doc Version 5.2 Page 6 “Speaking as parents we are so grateful that caring team.” has such a professional and Staff attend many different training programmes that equips them with the skills to work with the service users living at this home. Meals are prepared and cooked by the home’s housekeeper and are both nutritious and attractively served. The service users’ individual nutritional needs are considered as well as their likes and dislikes. Such information is recorded clearly in the care plans and was confirmed by the housekeeper who demonstrates clear knowledge about the needs and likes of the service users. 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. All Saints Vicarage DS0000015776.V333296.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 All Saints Vicarage DS0000015776.V333296.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): 1,2,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of information enables service users to make an informed choice about where they would like to live. However the information could inform service users more fully by including the range of fees charged. The good multidisciplinary pre-admission assessments that are in place demonstrate service users’ needs and aspirations and assist the home to make an informed judgement as to whether they can meet these. EVIDENCE: A comprehensive Statement of Purpose and Service User Guide that clearly demonstrate the aims and objectives of the service had been developed. The range of fees charged by the home is not included in these documents, however the manager stated that individual costs, based on individual need, are readily available during discussion with the management of the service. Individual care files include contracts that determine the terms and conditions of each service’s user stay at the home. So that they are more accessible to service users these are in picture format and include the amount of costs paid by the individual. The full cost of the fees charged by the home and a breakdown of how these are paid are kept in a separate confidential file. All Saints Vicarage DS0000015776.V333296.R01.S.doc Version 5.2 Page 9 The organisation has comprehensive policies and procedures regarding the admission process. As much information as possible is gathered about an individual from the referring agencies, other professionals involved in the person’s care and their families or representatives. The home itself also carries out a detailed assessment of need. Pre-admission assessments submitted by care managers and medical professionals if appropriate, were in place. Valuable information in relation to individual service user’s behaviours and how these relate to autism is presented and clearly transferred to individual care plans. Staff felt that this gives them a good understanding of the person and the reasons behind their behaviours. One member of staff commented, “ The information provided gave good insight into behaviours and the reasons why.” There has been one new admission to the home since the last inspection. The manager confirmed that a sensitive, gradual introduction to the home took place during which time the service user and staff had time to get to know each other. A multi disciplinary team involved in the service user’s care were available during the transition process that gave staff time to seek advice when needed. A relative commented, “Every effort was made to make the transition smooth and less anxious for …, he has settled wonderfully.” Staff confirmed that they receive training relevant to individual needs and were observed to have the skills and understanding to meet service users’ needs effectively. All Saints Vicarage DS0000015776.V333296.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff effectively support service users to make decisions about their care and promote their independence and this is reflected in each service user’s care plan. EVIDENCE: Each service user has a care plan that is monitored monthly and reviewed annually. These are written in detail and are informative in relation to the individuals’ personal, social and health care needs. The care plans inform staff of individual service user’s difficulties relating to autism and how this might affect different aspects of their lives. Guidelines are in place for staff to follow so that the service user is supported through a consistent care practice approach. All Saints Vicarage DS0000015776.V333296.R01.S.doc Version 5.2 Page 11 Clear communication is a high priority. Each care plan has an individual communication profile that clearly states the individual communication needs. One care plan states that the demonstration of aggressive behaviour might reflect the individual’s frustrations at not being given the chance to communicate effectively. Guidelines are in place in relation to encouraging the service user to effectively communicate verbally and through the use of gestures. Great effort is made to promote service users rights and to enable them to make decisions. However although it was evident when reading care plans that the likes and dislikes of individual service users are clearly recorded, it is acknowledged that due to their complex needs, offering choices might cause anxiety. To avoid this choice is often limited and often the choice of two options is given, or in some cases the choice is made for the person by staff. This is achieved by using the knowledge recorded about the service user. Detailed information and guidelines in care plans reflect this and where assessments proved necessary risk management plans were in place. Risk assessments are an integral part of the care plan and risk management plans support service users to safely take part in everyday lifestyles. They are discussed with the representatives of the service users, signed by them and reviewed regularly. A discussion took place with the registered manager and her deputy manager in relation to the use of person centred planning. Both acknowledged their interest and made reference to a future training event that they plan to attend. All Saints Vicarage DS0000015776.V333296.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported to take part in a variety of leisure and community based activities and as a result live a valued lifestyle. The service supports service users’ rights and successfully supports them in maintaining relationships with family and friends. Meals are healthy, nutritious and attractive, and are prepared to meet the individual dietary needs of each service user. EVIDENCE: Due to the age and energy of most of the service users living at this home, many of the activities enjoyed include those of a physical nature, for example swimming, walking, horse riding and bike riding. All Saints Vicarage DS0000015776.V333296.R01.S.doc Version 5.2 Page 13 In addition to this service users have access to an activity resource centre developed by the care provider, that provides a climbing wall, ball game areas and a hydrotherapy pool. This facility provides a resource that is used by other services run by the provider in the area of Sunderland. It provides a space that can offer a more secure environment that meets particular needs. One service user who had used this facility and who “was now becoming more tolerant to change” is now being introduced to more community-based facilities. For this person this was an important step in their transition to community-based activities. One member of staff described how one service user enjoys going to the swimming pool in the community. Activities also include walks in the local country parks and visits to local shops. One care file described how one service user liked to go ice-skating. So that service users are kept safe but given the opportunity of experiencing new activities or those that may impose a risk, risk assessments are carried out and risk management plans are put in place. Although it was evident that service users take part in a variety of activities a comment from a relative indicated that there was room for further activities to be arranged for indoors, especially in the winter months. The manager agreed to address this. The atmosphere in the home was relaxed. Service users moved around the home confidently and freely demonstrating the ownership of their surroundings. One service user indicated to staff that they wanted assistance to put on their outdoor clothing and was later observed enjoying the weather outside in the garden. Records and photographs displayed in service users’ bedrooms, confirmed that the home encourages contact with family and friends to be maintained. Family birthday and other special dates are recorded in the care files and staff stated that service users are supported with correspondence. The manager stated that the menus are developed around peoples known likes and dislikes. The care plans also record the different foods that service users enjoy. One care plan clearly records the way food must be served in relation to the service user’s needs. Staff confirmed that the development of this plan of care was achieved with the guidance from a speech therapist. So that a consistent approach is achieved written guidelines are recorded for staff to follow. All Saints Vicarage DS0000015776.V333296.R01.S.doc Version 5.2 Page 14 The menus are healthy, tasty and nutritious and the observation of service users having lunch confirmed that they enjoy them. Service users were offered drinks regularly throughout the day. All Saints Vicarage DS0000015776.V333296.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): 18,19,20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users personal and healthcare needs are met in a flexible but consistent manner, reflecting a healthy lifestyle. Medication arrangements are appropriate to the needs of service users and are managed safely, ensuring that the welfare of the service users is safeguarded. EVIDENCE: Service users are supported to register and attend healthcare practices in the local community. Visits to the GP, dentist’s opticians and other health professionals are recorded in individual care files with the outcome of the visit. Staff work closely with healthcare officials involved in the lives of individual service users. A health profile is included in each care file and at a glance the reader can see what aspects of the individual ‘s health needs attention. Further details are found in the care plan. All Saints Vicarage DS0000015776.V333296.R01.S.doc Version 5.2 Page 16 Any health or behaviour changes that are observed by staff are clearly recorded in the care files. For one service user such observations and records assisted medical staff to quickly diagnose a serious medical condition. A community nurse who visits the home daily commended staff on their quick actions and the way in which they support the service user with their healthcare needs. Comments by the service user’s parents included; “ Staff have adapted well to new dietary and medical needs, we are really impressed with the level of care provided.” Risk assessments are in place in relation to the self-administration of medication and in relation to attending healthcare appointments. However a risk assessment had not been carried out in relation to one service user’s newly diagnosed medical condition. The manager agreed to address this oversight. Risk management plans generally assist staff to be aware of the risks involved in relation to the medical condition and the actions that may need to be taken. It was noted that service users generally looked fit and healthy and happy with their lives. The observation of the interaction of staff with service users demonstrates that personal support is delivered in a discreet and respectful manner. The administration of the lunchtime medication was observed. Medication is stored and administered appropriately. Staff have attended training in relation to the administration of medication. All Saints Vicarage DS0000015776.V333296.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): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to help protect service users from abuse and to seriously address complaints and concerns about the service. EVIDENCE: The home has a comprehensive complaints procedure, a copy of which has been given to each service user in picture format. Relatives of service users confirmed that they knew how to complain if they needed to. There have been no complaints made since the last inspection, however a relative and a health care professional have complimented the home on their good care practices. Staff spoken to confirmed that they received awareness training regarding abuse and adult protection, as well as training in relation to handling verbal and aggressive behaviour. The manager confirmed that most staff have attended training in relation to the local authority’s POVA (Protection of Vulnerable Adults) procedures and there are plans for another 12 staff to attend training in June and July. A copy of the local authority POVA procedures is available in the home. All Saints Vicarage DS0000015776.V333296.R01.S.doc Version 5.2 Page 18 The outcome of individual risk assessments carried out in relation to the selfmanagement of service users’ personal allowances concluded that each service user needs staff to support them with this task. The guidelines and practices in place follow the home’s comprehensive policies that aim to protect the service users from financial abuse. All Saints Vicarage DS0000015776.V333296.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): 24,28,30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service is homely, comfortable, and clean and provides service users with spacious private and communal spaces that are decorated and furnished to a high standard. EVIDENCE: All Saints Vicarage is set in its own grounds in a quiet location but near to local amenities. The décor is bright and the furniture uncluttered, allowing freedom of movement that meets and promotes the needs of the service users. All of the service users have single bedrooms that are individually decorated. The extensive grounds are kept tidy by a gardener and the general repairs are undertaken by a handyperson. All Saints Vicarage DS0000015776.V333296.R01.S.doc Version 5.2 Page 20 The refurbishment of the building, that included an extension to accommodate the individual needs of an additional service user, re-decoration throughout and some furniture being replaced, is now complete and as a result, a high standard of accommodation has been achieved. The choice of neutral colours gives a calming effect throughout the home and the choice of strong robust good quality furniture reflects the needs of the service users. However due to the sometimes “heavy” use of the furnishings a radiator cover has been damaged and the material on one of the sofa’s has been torn. The manager confirmed that the repairs have been reported and are waiting to be completed. There is a large driveway up to the house that is big enough for several cars and the home’s vehicle and large gardens surround the house to which service users have easy access. All areas of the home were exceptionally clean and tidy reflecting effective cleaning routines. Staff confirmed that they have attended training regarding infection control. All Saints Vicarage DS0000015776.V333296.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): 34,35,36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Robust recruitment & selection procedures and regular training opportunities ensure that service users are appropriately supported and protected by a competent and qualified staff team. EVIDENCE: Staff interact positively with service users, as well as being well focussed and organised. All were aware of the service users’ needs and the daily routines and all spoke positively about working at the service. There was a sufficient number of staff on duty, this numbered 6 in total, 3 being allocated to support one service user. A good training programme is in place, 17 out of 28 staff are trained to at least NVQ level 2 and all senior staff are working towards NVQ level 4. A training matrix identifies individual training needs, highlighting when mandatory training needs to be reviewed. Staff confirmed that they receive appropriate training to carry out their roles. All Saints Vicarage DS0000015776.V333296.R01.S.doc Version 5.2 Page 22 Training carried out includes health and safety, first aid, moving and handling, the safe handling of medicines and communication issues. New staff participate in an induction course and have to achieve elements within set timescales. The programme is comprehensive and shows how to support service users in an appropriate way. So that all staff understand the issues that surround learning disabilities they work through the LDAF (Learning Disabilities Award Framework). There was no evidence that staff had received training in relation to Equality and Diversity, neither could the manager confirm that there were plans to address this subject. The manager agreed that staff should be brought up to date with the issues surrounding Equality and Diversity and would address this. The files of 2 recently recruited members of staff were examined. Both included completed application forms and 3 satisfactory references from former employers. One included a satisfactory CRB (Criminal Records Bureau) check, however although a satisfactory POVA First check has been received for the other, the full CRB check had not been received. The service manager confirmed that the member of staff is working under direct supervision only and that the CSCI (Commission for Social Care Inspection) had been consulted on this matter and were satisfied that the appropriate procedures were being followed. Staff are regularly supervised and records kept. These confirmed that apart from general issues being discussed, a general theme is also included. The latest theme related to fire procedures and an issue reported to the CSCI. However there was no formal supervision notes in place for 2 people who had started work in December 2006 and January 2007, this was brought to the attention of the manager who agreed to immediately address it. All Saints Vicarage DS0000015776.V333296.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): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager, who is well supported by a deputy manager and a competent senior staff team, provides good leadership and runs a service that has effective monitoring systems that are focussed on the best interests of the service users. EVIDENCE: The manager is well experienced in this line of work and has a good understanding of the service users needs and the issues surrounding autism. She has successfully completed the Registered Manager’s Award (RMA) and NVQ 4 in Care and is up to date with mandatory training. All Saints Vicarage DS0000015776.V333296.R01.S.doc Version 5.2 Page 24 This home has been awarded the Investors in People Award and has effective quality assurance and monitoring processes in place that are followed by staff. The results of the service users surveys are recorded every two years, a copy of which is forwarded to the CSCI. Records are kept in relation to health and safety and monitored appropriately. This means that service users receive and live in a safe service. All Saints Vicarage DS0000015776.V333296.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 2 2 3 3 X 4 X 5 3 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 3 29 X 30 4 STAFFING Standard No Score 31 X 32 X 33 3 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 2 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 3 X 3 X X 3 X All Saints Vicarage DS0000015776.V333296.R01.S.doc Version 5.2 Page 26 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 5(b) Requirement The Service User Guide must include, in with the copy of the terms and conditions in respect of accommodation to be provided for service users, the amount and method of payment of fees. Timescale for action 31/05/07 2. YA9 13(14)(c) So that medical conditions do 31/05/07 not impede on the lifestyle chosen by individual service users a risk assessment must be carried out and risk management plans put in place, so that staff are guided to safely support the individual service user. The registered manager must ensure that staff are appropriately supervised. This is particularly in relation to the staff who have not received supervision since commencing work in December 2006 and January 2007. 31/05/07 3 YA36 18(2) All Saints Vicarage DS0000015776.V333296.R01.S.doc Version 5.2 Page 27 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 YA6 Good Practice Recommendations The plans to further improve the care planning system and process in relation to including person centred planning and recording is encouraged. So that high standard of the environment is not compromised, the registered manager should ensure that the identified repairs needed to the radiator cover and the sofa are addressed. So that staff are brought up to date with the issues surrounding Equality and Diversity training should be offered in relation to this subject. 2 YA24 3 YA35 All Saints Vicarage DS0000015776.V333296.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South Shields Area Office 4th 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 All Saints Vicarage DS0000015776.V333296.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!