Inspection on 18/04/07 for Beach Road (101)

This inspection was carried out on 18th April 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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 Beach Road (101) South Shields Tyne And Wear NE33 2LZ Lead Inspector Elsie Allnutt Key Unannounced Inspection 18th April 2007 10:00 Beach Road (101) DS0000068422.V334447.R02.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 Beach Road (101) DS0000068422.V334447.R02.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. Beach Road (101) DS0000068422.V334447.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beach Road (101) Address South Shields Tyne And Wear NE33 2LZ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0191 4563532 0191 4563532 beachroad@sjogcareservices.org.uk www.sjog.co.uk Saint John of God Care Services Carol Smith Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Beach Road (101) DS0000068422.V334447.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 14/12/05 Brief Description of the Service: 101 Beach Road is a four storey terraced house situated in South Shields and is registered to provide personal care and accommodation to four adults who have a learning disability. The home is situated near local shops, park and sea front. An office and sleep-in room are available on the fourth floor, the remaining areas of the house provide communal and personal accommodation for the service users. Each person has a single bedroom that has a lock and key, and décor is to the taste of the individual. All of the rooms in the house meet the required measurements of the National Minimum Standards. A spacious lounge is situated on the ground floor. The dining room, large dining kitchen and laundry are situated in the basement, and all but one of the bedrooms is situated on the first floor. One bedroom is situated on the ground floor. Access to all four floors is by a central stairway. There is a small garden to the front of the house and a courtyard that has garden furniture and a barbecue for activity in the warm weather to the rear. As well as supporting the people who live there with personal care tasks, the staff who work at the home assist residents in developing daily living skills and leisure activities. Residents are also supported to have short breaks and holidays of their choice away from the home. The service has developed a Service User Guide that informs prospective service users about the service, the aims and how these are met. A copy of the recent inspection report is available in the home for anyone to read. The fees charged by the home range between £603.61 and £894.53 per week. Beach Road (101) DS0000068422.V334447.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This planned unannounced key inspection took 7 hours over one day in April 2007. The views of four residents and three members of staff were sought. As some residents have communication needs their satisfaction of the service was interpreted not only through speech but the 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. Questionnaires were sent out to the relatives of the residents prior to the inspection and one was returned. This demonstrated their satisfaction with the service at 101 Beach Road. During a discussion with the manager at the beginning of this inspection, it was noted that the company, in relation to their preferred term of recognition had consulted the people who use the service. The outcome being that people who use the service prefer to be referred to, as residents not service users. This will be respected in this report. What the service does well: The quality of the décor and furniture in this home is very good and the house is kept very clean. This means that the people who live here are provided with an attractive, clean and comfortable place to live The friendly way residents and staff get on with each other gives a warm feeling that makes people living and visiting the home feel welcome. Residents are involved in a variety of different activities in the home and the local area around where they live. Staff accompany residents to local clubs and leisure facilities where they join other people who live in the area to take part in the activity that interests them. All of the residents enjoy holidays away from home. Residents choose where they want to go, sometimes with the help of staff. Some residents are going to Tunisia and Amsterdam this year and have recently enjoyed a trip to London. Some of the staff have worked at the home for many years which means that the residents know them very well. One resident said, “ The staff are good I like them all.” The staff know how to do their jobs well. This is because they go to on training courses to learn how to do their job properly and to learn new things about it. Beach Road (101) DS0000068422.V334447.R02.S.doc Version 5.2 Page 6 Every resident has a Life Plan that informs staff what residents need help with and how they want to live their lives. The Life Plans are written well and in a clear way. This guides each member of staff to support each resident in the way they prefer. Residents have recently asked for a new TV and better storage for their personal belongings. The manager and staff listened to this and plans are underway to put this in place. Residents know what to do if they are unhappy about anything. One person said, “If I am unhappy about something I talk to a member of staff and they listen to me and do something about it.” What has improved since the last inspection? What they could do better: So that the door can easily close and protect residents from the risk of harm in the event of a fire breaking out in the home, the plans to adjust the door to the resident’s bedroom that currently does not close properly must go ahead as soon as possible. This will also make sure that the resident’s privacy and dignity is maintained. Beach Road (101) DS0000068422.V334447.R02.S.doc Version 5.2 Page 7 So that all staff know what to do in the event of a fire breaking out in the home and how to keep residents safe, according to what shifts they work they must practice the home’s fire drill and receive fire instruction as directed by the Fire Regulations. For staff working night shift this must take place every three months. To further improve the Life Plans, thought should be given to developing them all in the person centred approach. This will further empower residents. 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. Beach Road (101) DS0000068422.V334447.R02.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beach Road (101) DS0000068422.V334447.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 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 is available which enables residents to make a fully informed choice about where they would like to live. The good multidisciplinary preadmission assessments that are in place demonstrate residents’ needs and aspirations and assist the home to make an informed judgement as to whether they can meet these. EVIDENCE: The Service User Guide is now called The Residents’ Guide. The service has developed a comprehensive Statement of Purpose and Residents’ Guide that clearly demonstrate the aims and objectives of the service. Both documents have been updated to include recent changes made in the Company. All care files include preadmission assessments from the referring agencies of the individual residents and an assessment carried out by the home. One included assessments made by the referring agency, healthcare professionals involved in their care, the Adult Training Centre that they attend and the individual’s relative. Beach Road (101) DS0000068422.V334447.R02.S.doc Version 5.2 Page 10 The home also carried out their own assessment and from that, the other information gathered and observations made during visits by the resident, they were able to make a judgement that they were able to effectively address the person’s needs. This information was also used to develop a plan of care. Beach Road (101) DS0000068422.V334447.R02.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed care plans and the staffs’ understanding regarding residents communication methods enables residents to be supported to make decisions, which at times may include taking risks and to direct their care in a way that they prefer. EVIDENCE: All residents have a care plan that is monitored monthly and reviewed annually and referred to by this service as a “Life Plan”. Residents have an active part in the development of these. Two residents were able to discuss the content of their Life Plans and demonstrate that they had a good understanding of what was written about them and why they were in place. Two residents are relatively independent and are able to verbally make their needs known while others rely on more support to communicate effectively. Beach Road (101) DS0000068422.V334447.R02.S.doc Version 5.2 Page 12 To enable residents to take the lead in their care, effective communication between residents and carers is encouraged and the individual communication needs are recorded in detail in the Life Plans. For one resident who uses very little verbal communication, the interpretation of different facial expressions and body language is recorded. This enables staff to interpret the resident’s likes and dislikes which are recorded clearly so that all staff are aware of their preferences when supporting the person to make decisions. Although the four residents have a diverse range of needs, all are treated equally with regard to the opportunities that are offered. Interaction with residents and staff confirmed this. Staff were observed giving time to all residents but ensuring that everyone had their needs met effectively. The manager confirmed that 1:1 support is given whenever possible, however residents are encouraged to develop their independence. One resident said, “ I am encouraged to choose the clothes I wear, but staff might say that wearing something different might be warmer.” Clear risk assessments are in place followed by clear risk management plans that guide staff how to support residents to minimise the identified risk. As a result of this process residents are encouraged to develop their experiences and skills. A risk assessment was in place in relation to using particular pieces of kitchen equipment for one resident. Records demonstrate that residents are supported to take charge of their own finances when possible and in accordance with the risk assessment and risk management plan. All of the care plans are good and written in sufficient detail to guide staff to support residents effectively. Parts of the care plans are written with a person centred approach. This empowers the resident and identifies them as the person in control of their life. However not all of the care plans are written in this style. This was discussed with the manager who agreed that a consistent way of recording the care plans is important and that by using a person centred approach could further empower all residents. Beach Road (101) DS0000068422.V334447.R02.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents 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 the rights of residents 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: All of the residents have individual weekly activity programmes that are evident in their Life Plans. These are varied according to individual preferences but confirm well-organised and active lifestyles. As part of their weekly routine two residents attend day centres on certain days of the week. Beach Road (101) DS0000068422.V334447.R02.S.doc Version 5.2 Page 14 However discussions with them confirmed that although they enjoy attending the centres they also enjoy a wide range of activities in the local community. The activities the residents take part in are reflected in the daily notes where comments also reflect the outcome of the activity. It was noted that since the last inspection residents have been given further opportunities to try new activities and as a result there has been an increase in the use of local community facilities. One resident discussed a health group that they have recently joined where they take part in activities in the gym and swimming pool, as well as enjoying the activity of walking. Two residents have recently joined a drama group that they said they enjoy. Staff enthusiastically discussed how they thought this activity was particularly assisting one resident with their personal development. Other activities enjoyed include, line dancing, 10pin bowling, water aerobics, shopping, beauty therapy and going to a local community based disco. One resident said: “I go out every night, it’s great.” Staff confirmed that they enjoy taking part in the activities with the residents. The Cultural and Spirituality section in the Life Plans record how the person prefers to live their life and includes the special things and people to them. Records include reference to family members, pets, daily routines and programmes watched on the TV. This acknowledges the individual lifestyle the individual prefers to live. Residents eagerly discussed a recent trip to London and a holiday planned to Tunisia. Staff confirmed that all residents have holidays planned to different destinations either in England or abroad depending on individual preferences. Risk management plans ensure that residents are safely supported to take part in their chosen activity and when necessary identifies when limitations might have to be set. This is an area that has been successfully addressed since the last inspection. Risk assessments why two residents do not have keys to the front door are in place. A varied nutritious menu is offered at the home. A picture diary is used so that residents can assist in the planning and choosing of different menus. Beach Road (101) DS0000068422.V334447.R02.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 good. This judgement has been made using available evidence including a visit to this service. Residents’ personal and healthcare needs are met in a flexible but consistent manner, reflecting a healthy lifestyle. Medication arrangements are appropriate to the needs of residents and are managed safely, ensuring that the welfare of the residents is safeguarded. EVIDENCE: Residents 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. Healthcare needs are clearly recorded in the care files and developed as a care plan if needed. Any health or behaviour changes that are observed by staff are clearly recorded in the care files and if needed action is taken to gain specialist healthcare advice. Beach Road (101) DS0000068422.V334447.R02.S.doc Version 5.2 Page 16 It was noted that residents generally looked fit and healthy and happy with their lives. One resident said: “ I am really happy living here.” Another said “ I feel happy and safe.” The observation of the interaction of staff with residents demonstrates that personal support is delivered in a discreet and respectful manner. Risk assessments are in place in relation to the self-administration of medication resulting in all residents that take medication needing support with this. Medication is stored and administered appropriately. Staff and records confirmed that staff only administer medication after receiving specialised training. Beach Road (101) DS0000068422.V334447.R02.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. Appropriate arrangements are in place which protect residents from abuse and seriously addresses complaints and concerns about the service. EVIDENCE: The home has a Complaints Procedure that is also in picture format, a copy of which was found in the residents’ care files. Residents know how to complain and who to go to if they are not satisfied with any aspect of the service. One resident said, “ If I’m not happy about something I tell them.” There have been no complaints recorded since the last inspection. 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 staff have attended training in relation to the local authority’s POVA (Protection of Vulnerable Adults) procedures, a copy of which is available in the home. The outcome of individual risk assessments carried out in relation to the selfmanagement of residents’ finances showed that each resident needs staff to Beach Road (101) DS0000068422.V334447.R02.S.doc Version 5.2 Page 18 support them with this task. However care plans show that individual residents are encouraged to take responsibility for their daily finances under guidance. The guidelines and practices in place follow the home’s comprehensive policies that aim to protect the residents from financial abuse. Beach Road (101) DS0000068422.V334447.R02.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): 24,27,30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is homely, comfortable, clean, safe and decorated and furnished to a high standard, therefore providing residents with spacious private and communal spaces in which to live. EVIDENCE: 101 Beach Road is situated in close proximity of the seafront and the town centre and has bus routes close by. There is a small garden area to the front of the house and there is a courtyard to the rear that has garden furniture and a barbecue for the warm weather. The manager stated that there are plans in place to address the wear and tear now showing on the front fascia of the building and there are also plans to replace the windows. Beach Road (101) DS0000068422.V334447.R02.S.doc Version 5.2 Page 20 The décor and furnishings inside the house are of a high standard. All residents have single bedrooms that are individually decorated. One of the bedrooms is currently being refurbished and new wardrobes were being fitted. The resident was keen to show the improvement this would make for the storage of their personal belongings. The thickness of a new carpet has meant that the door needs to be adjusted so that it closes fully. The manager confirmed that this was in hand and would be soon addressed. Another resident had great delight in showing their room and discussing the plans for their new wardrobes, also explaining how they would prefer the furniture to be rearranged. All of the residents have benefited from several other improvements made to the house since the last inspection. The kitchen has been refurbished with new kitchen unit doors, new freezer, dishwasher and oven and the lounge has a new TV and new chairs. The home has been decorated throughout resulting in a bright, clean environment. The residents confirmed that they were consulted about the choice of colours and also confirmed that it was at their request that the TV was replaced. The bathroom has been completely refurbished, with a new bathroom suite, shower cubicle, flooring and tiling. This now means that this room is safer, more attractive and comfortable for residents to use. The choice of neutral colours gives a calming effect throughout the home and the choice of good quality furniture reflects the needs of the residents. All areas of the home were exceptionally clean and tidy, reflecting effective cleaning routines. Staff confirmed that they have attended training regarding infection control. Beach Road (101) DS0000068422.V334447.R02.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): 33,34,35 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 residents are appropriately supported and protected by a competent and qualified staff team. EVIDENCE: There was an adequate number of staff on duty to effectively address the needs of the residents. Two residents were at day centres and two were at home. Two members of staff and the manager were on duty. The manager confirmed that it is the home’s aim to give all residents 1:1 support at some time during the week. Residents and records confirmed this. One resident discussed how they had attended a keep fit class the night before with a member of staff. Another resident was observed being assisted by a member of staff to go shopping. This staffing ratio enables residents to take part in interesting and valued lifestyles. Beach Road (101) DS0000068422.V334447.R02.S.doc Version 5.2 Page 22 The Company has recently agreed a new training contract with a training agency. This means that a training programme is allocated specifically for St John of God staff and the Company’s different homes in the area are guaranteed spaces for training events that meet the identified training needs. A training matrix confirmed that all staff are up to date regarding mandatory training. Other training courses recently attended include diabetes, personal hygiene, epilepsy and the Learning Disability Award Framework (LDAF) that is compulsory for all staff and part of the Induction Course. Records confirmed that further training is planned. The manager also confirmed plans for staff to attend a training course regarding Equality and Diversity. This is to be organised as a distant learning course with another company. The company provides new members of staff with a filofax type folder that includes information about the home and explains training requirements and opportunities. Staff are employed via robust recruitment procedures. A sample of staff files demonstrated that the necessary documents were in place, for example an application form, 2 written references and a satisfactory CRB check. This ensures that the staff who apply to work at the home are suitable to work with vulnerable people. Two of the files examined included those of staff that had been employed in the past 12 months Beach Road (101) DS0000068422.V334447.R02.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 her 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 of this service is fully qualified as a registered manager. She has achieved the Registered Manager’s Award, NVQ4 in Care and the NVQ Assessors Award. She is also up to date with mandatory training and attends training relevant to her role. Recent training includes issues around the Benefit System, Stress Management, the Mental Capacity Act, Presenting Training and Report Writing. Beach Road (101) DS0000068422.V334447.R02.S.doc Version 5.2 Page 24 Both residents and staff confirmed that they felt valued by the manager and the company and felt that their opinions mattered. This has created an atmosphere of openness and respect, that reflects on the quality of care and the quality of life experienced by the residents. This service has a quality assurance system in place that monitors and records all aspects of the service delivered. As well as seeking the views of the residents, the manager confirmed that satisfaction surveys are sent out to the residents’ relatives, staff at the daycentres and GPs. A copy of the annual Quality Review Report is to be forwarded to the Commission for Social Care Inspection (CSCI). The quality of the service is also effectively monitored during the monthly providers visits. Following such visits a detailed report is produced and issues addressed during the visit are related to the National Minimum Standards. Recommendations for the registered manager to address are made when appropriate. A copy of this report is forwarded to the CSCI (Commission for Social Care Inspection). Recommendations made by the Fire Service during a recent visit have been addressed. However when examining the fire log it was evident that the last fire drill was dated November 2006. Where staff work night shift fire drills and fire instruction must be practiced and delivered every 3 months. The manager agreed to address this. Beach Road (101) DS0000068422.V334447.R02.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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 3 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 X 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 X 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 X 3 X X 2 X Beach Road (101) DS0000068422.V334447.R02.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 YA42 Regulation 23(4)(c ) (d)(e) Requirement The registered manager must ensure that all staff that work night shift must practice fire drills and receive fire instruction every three months. Timescale for action 30/05/07 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 Refer to Standard YA6 YA25 Good Practice Recommendations The registered manager is encouraged to write all care plans in the person centred approach and to make sure that all staff are trained in relation to this. It is recommended that the plans to adjust the bedroom door where the new carpet has been laid go ahead as planned. Beach Road (101) DS0000068422.V334447.R02.S.doc Version 5.2 Page 27 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 Beach Road (101) DS0000068422.V334447.R02.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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