Inspection on 18/04/07 for Coanwood Drive

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 Adequate. 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 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Coanwood Drive 01/08/06

Coanwood Drive 10/11/05

Coanwood Drive 16/08/05

Coanwood Drive 14/01/05

Coanwood Drive 22/06/04

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 Coanwood Drive 22 Coanwood Drive Mayfield Glade Cramlington Northumberland NE23 6TL Lead Inspector Carole McKay Unannounced Inspection 18th April 2007 09:30 Coanwood Drive DS0000000605.V335661.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 Coanwood Drive DS0000000605.V335661.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. Coanwood Drive DS0000000605.V335661.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coanwood Drive Address 22 Coanwood Drive Mayfield Glade Cramlington Northumberland NE23 6TL 01670 739319 F/P 01670 739319 coanwood@stcuthbertscare.org.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) St Cuthberts Care Mrs Marie S S Johnson Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Coanwood Drive DS0000000605.V335661.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st August 2006 Brief Description of the Service: St Cuthbert’s Care is the charitable organisation providing the care at 22 Coanwood Drive. The property is owned and managed by the local authority housing department. The home is registered to provide care and support to seven adults with a learning disability. It is located in a residential area on the outskirts of Cramlington and is within walking distance of the town centre and public transport. Residents are accommodated at Coanwood Drive for a limited period of up to two years. During that time residents are helped by staff to develop the skills needed to live as independently as possible. A service is provided from Coanwood Drive to support people with learning disabilities who live in the community. Some of these people moved on from Coanwood Drive and levels of support vary to suit individual needs. Additional staff are provided for this service. The most up to date information that the Commission for Social Care Inspection has indicates that fees are £655.29 per week. Information about the service is available. The home has a copy of the Service User Guide and a copy of the last inspection report. Coanwood Drive DS0000000605.V335661.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The manager sent information to the inspector before the visit. This was used to help plan the inspection. The inspection visit took place over two days. The records and procedures were examined. Three staff and three service users were spoken to. The inspector met with the manager Mrs Marie Johnson. Surveys were sent out to service users, their representatives and professionals who have contact with the service. Four surveys were returned. A tour of the building was undertaken. What the service does well: What has improved since the last inspection? What they could do better: Make sure that the premises are maintained and jobs that need doing get done as soon as possible. This will keep the home looking at its best. Some improvements to the arrangements for assisting service users with medication need to be made to ensure that service users are safe from harm. Coanwood Drive DS0000000605.V335661.R01.S.doc Version 5.2 Page 6 Make sure that quality assurance systems work and that gaps in records are identified and amended. This will make sure that the record of care is complete. Make sure that the opinions of people who use the service are represented to the provider in the monthly visits, so that people feel their opinions are valued. Make sure that complaints that are passed to the provider are fully investigated to clear timescales and that the process and outcomes are fully recorded. This will give people who use the service greater confidence in the complaints process. 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. Coanwood Drive DS0000000605.V335661.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 Coanwood Drive DS0000000605.V335661.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home has information for service users about the how the service works. The people who live at the service will have their needs and wishes fully assessed. They will be involved in this throughout their stay at the home. EVIDENCE: The surveys from people who live at the service confirm that service users were given a choice about coming to live at Coanwood Drive. The care records contain full assessments that are carried out before and in the weeks after admission. These have a lot of information in them to do with all aspects of people’s lives. People’s strengths and the things they can do are identified, as well as the support they need. The assessment process continues throughout the time a person lives at the home. This is because the service is designed to assess and support people to move out and live independently in the community. Some of the assessments include things that service users have said about themselves and the things they want to achieve. The service has produced an easy to read brochure, and in this it states “the average stay at Coanwood Drive is 12 months, after which we assist people to move into their own accommodation, continuing to offer support at the level assessed as appropriate.” Coanwood Drive DS0000000605.V335661.R01.S.doc Version 5.2 Page 9 The professionals who returned surveys responded usually and sometimes to the question whether the service’s assessment arrangements ensure that accurate information is gathered so that the right service is provided. One person commented that the service asks for more information following receipt of the basic assessment as required. A further comment was made that the right service is planned and given to individuals through assessment and individual care plans. People living at the service said that they are asked to be involved in the assessment process. They said that they were satisfied that staff knew about their needs before their admission. Copies of the assessments that are carried out by service users’ care managers are also available. The Manager described how the needs of each person are assessed to ensure that the right level of support is provided at the time of their admission and during their stay. Risks to do with living independently or a person’s disability are assessed. Plans for managing unacceptable risks are in place. Coanwood Drive DS0000000605.V335661.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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Each service user has an individual plan of care. Service users are involved in writing these and staff support them to make decisions about how they live their lives. Service users are supported to take risks as part of an independent lifestyle. EVIDENCE: Once a person’s needs have been assessed, an individual plan for each person is drawn up. Copies of these are in the service users’ records at the home. These cover all aspects of life and include a section on the personal preferences of the service user. To help staff follow the plan and understand the service users, a section identifying things that work and things that don’t work for the service user is included. Also peoples’ fears and concerns are written down along with how dreams can be turned into steps that are achievable. Coanwood Drive DS0000000605.V335661.R01.S.doc Version 5.2 Page 11 Goals for making practical improvements towards independence are written down. After this each service user meets with the key worker who is helping them, to look at how well these plans are working. These are called Goal Evaluation Meetings (GEM) and they take place once per month. Notes from these meetings are kept in service users’ records. This helps service users to make their own decisions. Service users said that they could tell their key worker about any problems they have at these meetings. Service users are encouraged to take responsible risks as they go about their daily lives. Risks are carefully assessed and staff look at these from time to time and at the GEM meetings. Information that care managers give to the service and details of any risk assessments they have conducted, are sent to the home before an admission can take place. The home has a pre-admission assessment. This is used to establish how identified risks will be managed within and outside of the Home. Any risk assessment information is added into the service user plan. Completed risk assessment information was available in all of the care records examined. The professionals who returned surveys responded always to the question whether the service provided support to individuals to live the life they choose wherever possible. And responded always to the question about whether the service responds to the different needs of individual people. At the last random inspection of the home a requirement was made that the service should consider how service users are guided in staying safe. This is being addressed. This will help service users who spend time in the community, and when travelling unsupported by staff, to carry out their own assessments of risk. Coanwood Drive DS0000000605.V335661.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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who use the service are supported by staff to become part of, and participate in, their local community. They are encouraged to form meaningful relationships with staff and other people living there. Their rights are recognised and this helps them to lead valued and fulfilling lives. Their involvement in, and responsibilities for, the Home’s daily routines is encouraged. This helps them to work towards achieving more independence. People are able to take part in age, peer and culturally appropriate activities. A healthy diet is encouraged and the people living at the service have a say in planning the menus. EVIDENCE: Each service user has a service user plan. These include goal plans to support people who use the service with managing specific areas of responsibility in their lives. Where people need a specialist care plan, this is also carried out by the person’s care manager. One of the people using the service has one of Coanwood Drive DS0000000605.V335661.R01.S.doc Version 5.2 Page 13 these. This person was aware of this and said that she was soon going to a meeting to discuss this. Service users are encouraged to make decisions about their plans. Each month they meet with their keyworker to discuss their goals. These meetings are recorded in full and I saw these at this inspection. A comprehensive risk assessment is carried out for each person receiving the service. These are updated regularly and whenever new risks are identified. For example, risks have been identified recently for a person using the service who regularly uses a local social club independently. The risk assessment is in the process of being updated. Part of this involves specialists from another service working with the service user in identifying risks for themselves. Plans for managing risks are described in the service user plans. The manager is in the process of considering the requirement re staying safe policies/procedures for staff and service users. Service user plans at Coanwood Drive have a section dealing with education and occupation. Each service user has a weekly programme of activity that they are involved in devising. These are updated each week and show that each person has periods of engagement with work related and/or educational services. Routines are individual to each service user. During the inspection some service users were at home during the day and other people were out at services or work. Free time to relax and do nothing is also planned in. Visits to and from friends, including girlfriends and boyfriends, are planned out so that the people living at Coanwood sustain relationships that existed before they moved to the home. The home has rules. These have been put together through discussion with the people who live at the home and are written down. The service users said that they knew what the rules are. All the service users who were asked about these said that they thought they were reasonable. But some service users feel that these rules are not complied with by all persons and two people said that the staff are not consistent in ensuring compliance. Service users said that they could discuss this at the meetings they have with the staff, but they feel nothing is done about this. Menus are planned out for evening and weekend meals. The people using the service help put these together. At the inspection I saw staff supporting individual service users to plan and prepare their own meals. During the discussions about the meals healthy eating was discussed. Coanwood Drive DS0000000605.V335661.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Personal support is provided to service users in line with their abilities and preferences. Where needed specialist support is used. Service users’ rights to look after themselves are respected, with arrangements to safeguard service users. The medication checks that are carried out do not always identify weaknesses in these arrangements. EVIDENCE: There was evidence in the files that the people using the service are supported, as necessary, to obtain advice on health and personal matters through the use of local GP practices and other support services. The care records show that specialist help is used when necessary. These arrangements are reviewed regularly. Service users attend appointments independently where they can and support is provided for some people. A medication policy is in place for staff to refer to. Some of the people living at Coanwood look after their own medication. A small amount of medication is held for safekeeping by the staff for some service users. The risk assessment Coanwood Drive DS0000000605.V335661.R01.S.doc Version 5.2 Page 15 process identifies who needs help with this and care plans are in place to describe the arrangements. Omissions were found in medication administration records (mar) and there was evidence that mar sheets had not been updated to reflect the amount of self-administering. The manager, Marie Johnson, had counter signed these records. Marie acknowledged that she had failed to spot these errors. The medication procedure does not state what staff should do if medicines are refused. Training in medication administration is carried out for staff. This is done ‘in house’. The training manual is a very thorough but a weighty document. The medication storage is adequate. The home has no controlled medication in stock but no register for these either, so there is nowhere to properly book this in if it were prescribed for a person living at the service. Coanwood Drive DS0000000605.V335661.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Procedures are followed to protect service users. Service users are confident to make complaints and expect that these will be addressed. The provider has not demonstrated that service user’s concerns are treated seriously. The procedure for this could be made clearer. EVIDENCE: The home has a policy and procedure for protecting its service users. This complies with guidance issued. An adult protection issue has been handled properly, since the last inspection. The staff training schedule shows that staff are due training in safeguarding adults. There are no dates planned in for this to be delivered. The service user guide includes information about how to make a complaint. In service users’ surveys, all those who responded said that they knew who to speak to if they were unhappy and knew how to make a complaint. The home keeps records of complaints. These show that complaints are taken seriously and internal investigations are carried out. However, some service users said that they did not feel that some recent concerns were addressed by the staff team, or were not addressed consistently. One complaint, which was referred up to the provider, did not result in a response from a provider representative and the complaint has not been resolved. Coanwood Drive DS0000000605.V335661.R01.S.doc Version 5.2 Page 17 The complaint procedure is not clear about timescales and who will investigate complaints when they are passed to the provider. The professionals who returned surveys responded always to the question whether the service has responded appropriately to concerns. Coanwood Drive DS0000000605.V335661.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 28, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is clean and comfortable. Maintenance could be managed better and made easier. The layout of the home is not ideal. EVIDENCE: Coanwood Drive is comfortably furnished and the home is clean throughout. Local bus routes pass by near the home and service users said that they use public transport regularly. The premises are in keeping with the local housing and no signage denotes that it is a registered home. There is a system for auditing the fabric and fittings of the building. The recent audit had identified that the shed needs attention and the front flowerbeds of the home need to be weeded. The weeds detract from the appearance of the home. No action plan had been identified. The service users’ amenity area is situated at the rear of the house. The front is used for parking. The amenity area includes lawns, flower beds, a patio and barbecue area. Staff from the home look after these areas. The home has one living room, one dining room, an office, utility and a bathroom and a kitchen on the ground floor. The Coanwood Drive DS0000000605.V335661.R01.S.doc Version 5.2 Page 19 bedrooms are all on the first floor. These rooms are quite small. The living room, dining room and office are accessed from the front door through the kitchen. There is no alternative communal area. Visitors are accommodated in the office or in the dining or living room. The service users said that this can make things difficult at times. For example, if some people are wanting to watch the television in the living room and another person has visitors. Washing machines are located in the utility room. This is accessed directly from the main entrance corridor, so that people who use the service do not need to take laundry through food preparation areas. The maintenance schedule is being followed. The dining room was in the process of being decorated on the day of the inspection. Recommendations from the previous inspection to do with improving the front aspect of the home and communal space, have not been acted on. New locks have been fitted to the main doors. The doors are in a poor state of repair and the work carried out highlights that they are in need of repair or replacement. The rest of the building is adequately decorated and furnished. Communal areas are clean. The home employs a cleaner. Service users are expected to look after their own rooms. The file for the new member of staff included training in the control of infection. Risk assessments for safety have been carried out. Coanwood Drive DS0000000605.V335661.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are properly recruited and receive good basic training. On going and special training is also offered. This is now linked to the needs of the service users. EVIDENCE: Since the last key inspection 3 staff have left. There has been a small number of hours given to agency staff during this period. Staff have now been replaced and the home has a full staffing complement. 10 care staff are employed, two of whom are part time. One domestic is employed for 5 hours per week. 207 care hours are dedicated to the service. Additional hours are allocated to the outreach service. The manager said that she is considering ways in which the hours available in the home can be used more effectively. For example, to be able to offer more one to one support at peak times. Or when the people who use the service are admitted, or are moving on from the service. This would mean that the support could be delivered better when people need it. One of the people living at the home said that there should be more male staff. Since the last inspection two male staff have left. One of the existing staff is Coanwood Drive DS0000000605.V335661.R01.S.doc Version 5.2 Page 21 male. Two of the service users are male. Staff work alone at night. At the last random inspection a requirement was made about staff staying safe. This has been addressed. The home has a staff training plan for the coming year. This matrix shows that staff have had mandatory training and are scheduled for refresher training in these areas. Two of the care staff have a national vocational qualification (NVQ) at level 2. Four staff hold NVQ level 3 qualifications. The new staff member said that the induction training was well underway and that it had been thorough. There was evidence in this person’s file that mandatory training had been undertaken. Induction workbooks are available. Fire instruction was given on 16.3.07. The recruitment application was on file. This was signed and dated. It gave a good history but a gap of one year was not explored and recorded. The manager said that the interview record held this information and it had been sent to head office. There was evidence that a clear criminal record check (CRB) had been received but the original document was not on file. The manager said that these are held at the head office of the organisation. It was recorded that this had been carried out at an enhanced level for work with adults. Two written references were available. The Manager said that two staff and four service users are involved in the interview. The professionals who returned surveys responded always or usually to the question whether the manager and staff demonstrate that they have the right skills and experience to support individuals’ care needs. The manager, Marie Johnson, said that specialist training needs were now considered at each one to one meeting with staff. One of the experienced staff said that she thought some recent training had been identified from looking at the needs of the service users as well as staff needs in meeting these. Assertiveness training was given as an example. Coanwood Drive DS0000000605.V335661.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service is safe and regular checks take place. The auditing process needs to be refined to ensure that all identified problems are addressed. The quality assurance process should take account of the views of service users. This will ensure that service users feel involved and staff will have an objective measure of how well they are supporting service users. EVIDENCE: The registered manager has the required qualification and experience. There is a safety and maintenance audit process. Members of the staff team hold responsibilities to do with this. The staff are not involved in moving and handling of people but they receive training in moving and handling of loads. First Aid and Health and Safety training is provided to staff. Coanwood Drive DS0000000605.V335661.R01.S.doc Version 5.2 Page 23 The communal areas were considered at this inspection. Redecoration in the dining room is underway. The records show that safety risk assessments are carried out for fire, hazardous substances, and infection. Guidance about these things is written down and available for staff. Induction and regular up dated training is provided to staff in health and safety, first aid, food safety and fire safety. The fire alarm and fire equipment tests and servicing is recorded and up to date. Portable electrical appliances are tested annually. These were last tested in October 2006 and the records show that these all passed. None of the staff has done the competent person fire training but one member of staff has been identified to do this. This person said that she was waiting for a date for this. The home has a fire risk assessment but this does not determine the frequency of fire instruction. Regular meetings take place between individual service users and their key workers. Also, group meetings take place every month. These meetings are recorded. Action plans are developed from these. Service users said that they are encouraged to voice their opinions. One of the service users said that she thought they should have an opportunity to meet as a group without staff being present. A representative from the organisation that provides the service, St Cuthbert’s Care, visits the home once per month. Reports are produced from these visits, but these do not demonstrate how service users and their representatives are involved in influencing the quality of the service. Reports for the months of February and March 2007 were not available. Coanwood Drive DS0000000605.V335661.R01.S.doc Version 5.2 Page 24 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 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 2 23 2 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 2 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 4 14 x 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 2 x x 2 x Coanwood Drive DS0000000605.V335661.R01.S.doc Version 5.2 Page 25 Yes 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 Requirement Timescale for action 30/04/07 4,Schedule The following information about 1 the outreach part of the service must be provided: The number of service users being supported by the outreach service. Details of ownership of the houses occupied by service users. What type of support is provided to service users by the outreach part of the service When services commenced. How these services are funded. 2. YA20 13(2 ) Ensure that: All staff are provided with external accredited medication training. A controlled drug register is obtained. 30/06/07 Coanwood Drive DS0000000605.V335661.R01.S.doc Version 5.2 Page 26 Changes to administration arrangements are updated on the mar sheet as soon as they ocurr. Amend the medication procedure to clearly describe what staff are expected to do when medication is refused. Revise the complaints procedure to include the stages, timescales and process for internal investigations. 3. YA22 22 31/07/07 4. 5. YA23 YA34 Record in detail the investigation and any action taken and outcome of complaints made. 18(1)(c)(i) Staff must receive up to date 31/07/07 training in the protection of vulnerable adults. 19 CRB certificates must be 31/08/07 Schedule 2 available for inspection. Or where an umbrella organisation or corporate body is used the minimum expectation is that on receipt of the disclosure the following information recorded in a letter from the body carrying out the CRB check should be issued to providers: The name of the person; Date of disclosure; Level of disclosure; Including poca check (if requested ); • Including pova check (if requested ); • Disclosure reference number; • Date pova first check received ( if this was sought); and pova first reference number. Letters must be kept on file and be available for inspection at the home. • • • • Coanwood Drive DS0000000605.V335661.R01.S.doc Version 5.2 Page 27 6. YA39 26 Quality assurance visits to the service must include interviews with service users. Regulation 26 visit reports for February and March 2007 to be sent to inspector. One person, who is trained as competent, to update the fire risk assessment and determine the frequency of fire instruction for staff and service users. 30/06/07 7. YA42 23(4), 18(1)(c)(i) 31/07/07 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. Refer to Standard YA24 YA28 Good Practice Recommendations Serious consideration should be given to improving the front aspect of the home with low maintenance land scaping. Serious consideration should be given to providing an alternative communal space and/or meeting room. 2. YA22 Complaints made to the provider should be responded to formally by the provider. Coanwood Drive DS0000000605.V335661.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Coanwood Drive DS0000000605.V335661.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. 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