Inspection on 27/06/06 for Denecroft Care Home

This inspection was carried out on 27th June 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Denecroft Care Home 25/07/07

Denecroft Care Home 24/11/05

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

CARE HOMES FOR OLDER PEOPLE Denecroft Care Home 200 Newburn Road Throckley Newcastle Upon Tyne Tyne & Wear NE15 9AH Lead Inspector Elaine Malloy Key Unannounced Inspection 27th June 2006 09:30 X10015.doc Version 1.40 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 DS0000065918.V290899.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 Older People. 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. DS0000065918.V290899.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Denecroft Care Home Address 200 Newburn Road Throckley Newcastle Upon Tyne Tyne & Wear NE15 9AH 0191 2676422 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) Mr Sunny Okukpolor Humphreys Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places DS0000065918.V290899.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th April 2006 Brief Description of the Service: Denecroft is a care home that provides personal care for up to 15 older people. The home is located within a residential area of Throckley in Newcastle upon Tyne. It was built in 1911 and the property was converted to a care home and has been extended. The home is over two floors with a passenger lift. There are 11 single and 2 double bedrooms. Both double rooms were currently used for single occupancy. No bedrooms have en-suite facilities. Two bathrooms and 4 separate toilets are provided. There is easy access by public transport. Local amenities and shops are available in Throckley and Newburn. The current weekly fee is £355 for residents funded by the Local Authority or who are privately funded. DS0000065918.V290899.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection. It was carried out by one inspector over 1 day and took 6½ hours. Key standards were inspected through discussion with the manager, staff and residents, examining the home’s records and touring the building. Surveys were made available to residents and their relatives/visitors to get feedback on the service. Areas that needed improvement from the previous inspection were checked. What the service does well: Residents spoke positively about living at the home. Comments included ““I’ve never been so well cared for”, “They’re all lovely here”, “I’ve settled well”, “We’re very well looked after”, “It’s a very good home”, “Staff are kind and nothing is a bother”. New residents have their care needs thoroughly assessed before they move into the home. The assessments are then updated monthly to keep check on changing needs. Good standard care plans are recorded for resident health, personal and social care. Residents’ health care needs are met. A range of social activities and outings are offered. Residents are encouraged to keep contact with family, friends and the local community and make choices and decisions in daily living. Residents were complimentary about the meals provided and said they enjoyed the food. Residents understand how to make a complaint. There are procedures for protecting vulnerable adults. There is a stable team of staff and appropriate care staffing levels to meet resident needs. Staff were being provided with training relevant to caring for older people, and individual supervision. Resident finances are suitably safeguarded. Systems are in place to ensure health and safety requirements are met. DS0000065918.V290899.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. DS0000065918.V290899.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000065918.V290899.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using evidence gathered both during and before the visit to this service. Potential residents have their care needs thoroughly assessed before admission to the home is agreed. EVIDENCE: The care records of two residents admitted to the home in recent months were examined. Social workers assessments had been obtained. Information was provided by health professionals for one resident who was in hospital prior to admission. The manager had carried out thorough pre-admission assessment of care and support needs. DS0000065918.V290899.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using evidence gathered both during and before the visit to this service. Residents have well recorded plans that clearly demonstrate how their care needs will be met. There are suitable arrangements in place to access medical professionals and meet resident health care needs. The standard of record keeping for medication has improved and all care staff have received medication training. Residents confirmed that their privacy and dignity is respected. DS0000065918.V290899.R01.S.doc Version 5.2 Page 10 EVIDENCE: A range of assessment tools are completed for each resident to identify health, personal and social care needs. Assessments were being updated monthly; this is a good standard. The majority of care staff have been provided with in-house training on care planning from the manager. A sample of care plans was examined. Plans were in place for all assessed needs. There has been significant improvement to care plan recording. Interventions were very personalised and showed what the person can do for themselves and where assistance from staff is required. There was evidence of assessment of risks and plans were devised to demonstrate how risks were to be minimised or managed. Care plan evaluations were completed monthly with a good level of detail. The content of daily reports had also improved and entries were now being numbered to correspond to care plans. Residents use 2 local GP practices. The District Nurse was currently visiting twice weekly. Resident medical history is documented. All visits and appointments with medical professionals are recorded separate to daily reports. There was evidence of care plans related to health needs, for example rheumatoid arthritis, and pressure area care. Needs associated with continence, moving and handling and risk of falls are assessed and care planned. Three residents have toileting programmes to monitor and promote continence. The home has sitting weighing scales. Weights are completed at least monthly. Nutritional assessment was being introduced. All care staff have now undertaken medication training. At the last inspection there was an outstanding Requirement that there must be no gaps to signatures/codes in medication administration records. Medication charts were examined. These were appropriately recorded, with no gaps. The manager agreed to make sure that handwritten directions were added to pre-printed charts to show where prescribed creams/ointments are to be applied. Aspects of resident privacy and dignity are built into care plans. Staff are instructed to use discreet intervention and explain what they are about to do when assisting residents with personal care. Medical examination/treatment and personal care takes place in the privacy of the resident’s bedroom. Residents told the inspector that staff ensure their privacy and dignity is respected. DS0000065918.V290899.R01.S.doc Version 5.2 Page 11 Residents are asked the name they wish to be addressed by and this is recorded. During the course of the inspection staff were seen to address residents in a courteous manner. No bedrooms are currently shared as double rooms were being used for single occupancy. Residents are informed that the home presently has all female care staff. A cordless telephone is available for resident use and calls can also be made/received in private in the office. Mail is given directly to residents unopened, or kept for relatives at the resident’s request. Residents clothing is identified to make sure it is returned from the laundry to the right person. Individual wash bags were being purchased for tights, stockings and socks. DS0000065918.V290899.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using evidence gathered both during and before the visit to this service. Residents choose daily social activities and outings that they wish to be provided. Supported is offered to maintain contact with relatives, friends and the local community. Residents are encouraged to make choices and decisions in daily living. Residents enjoy the meals provided and can have alternatives to the menu. EVIDENCE: Residents have their social and spiritual needs assessed and individual care plans. Activities are forward planned but are subject to change according to resident wishes on the day. Activities and outings had been discussed at a recent resident meeting. A social diary is kept in which staff record activities that have taken place. These included bingo, painting and drawing, films, reminiscence, cards, dominoes, sing-a-longs, manicures, armchair exercises, games/quiz. There had been outings for a pub lunch and visits to a local DS0000065918.V290899.R01.S.doc Version 5.2 Page 13 community centre ‘The Grange’. Further outings were planned to Whitley Bay and Cullercoats, and other destinations that were to be decided by residents. Recent events included a pie and pea supper and visiting entertainer. On the afternoon of the inspection residents had chosen to watch World Cup football and tennis at Wimbledon on the two televisions on the lounge. Chocolate and fresh fruit and drinks were provided. There was evidence within care plans of welcoming visitors and offering hospitality. The home has an open visiting policy. The manager said that relatives are supportive. Residents are supported to make use of nearby amenities such as the community centre, shops, and pub and go for local walks. Religious services are not held at the home. Arrangements can be made for residents to attend places of worship or have visits from clergy. A layperson from a Church of England church was currently visiting very 1-2 months. Residents are encouraged to continue to manage their own finances. In practice relatives and solicitors provide assistance where needed. Management do not take responsibilities for individuals’ finances, other than the safe keeping of cash for personal spending. Information is available to residents on advocacy services. The extent of personal possessions to be brought into the home is agreed with new residents before admission. An example was given of this occurring with a new resident who was supported to bring in items from their house. Access to personal care records is facilitated during assessments and residents are asked whether they wish to sign their care plans. Records are also shown and discussed at reviews of individuals’ care. The home has a 4-week cycle of menus. Breakfast consists of cereals, toast and cooked items daily. Lunch and tea are set meals, however residents can request alternatives. Snacks and milky drinks are served for supper. Food had been discussed at a recent residents meeting and all present had said they like the meals. Examples were seen of relevant care plans. One plan had been devised at the request of the resident who was concerned about weight gain. This was well recorded. The other plan related to the resident’s nutritional needs. Advice was given to build in high calorific snacks and drinks; the manager changed the plan to incorporate these. The cook fortifies food. One resident has adapted cutlery, and another resident requires assistance with feeding, though can manage ‘finger food’ independently with prompts. The inspector dined with residents at lunch. Tables were nicely set with tablecloths, serviettes and condiments. The meal was served promptly and extra portions were offered. Cold drinks were served with the meal. Each resident spoken with said the meal and food generally was very good. Most said they did not usually ask for anything different to the menu as they enjoyed the meals provided. A carer was observed assisting a resident with feeding. She sat beside her and provided discreet help at the resident’s pace. DS0000065918.V290899.R01.S.doc Version 5.2 Page 14 The carer was encouraging, talking to the resident and asking if she was enjoying the food. DS0000065918.V290899.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using evidence gathered both during and before the visit to this service. Residents are aware of how to make a complaint and any complaints received are suitably investigated. Procedures are in place to protect vulnerable adults from abuse and further staff training is being organised. EVIDENCE: Residents confirmed that they would know how to make a complaint. No complaints had been received in the period since the last inspection. The provider had investigated a complaint made in December 2005 that resulted in disciplinary action with two staff who no longer work at the home. Records relating to the investigation were submitted to the Commission. The home has policies and procedures on prevention of abuse, protecting vulnerable adults and informing on bad practice. Four staff were booked to attend training on safeguarding adults. The manager had experienced difficulties in getting this training for all staff. She was therefore arranging to provide in-house training linked to the home’s own policies and procedures. The registered provider was referring a former carer to the Protection of Vulnerable Adults (POVA) list, for them to consider if she should be included in the list. DS0000065918.V290899.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using evidence gathered both during and before the visit to this service. A range of improvements has been made to the building that benefits residents. The home was kept clean, hygienic and comfortable. EVIDENCE: The home’s owner and the manager have prioritised work needed to the building. The kitchen was due to be refitted the day following the inspection. Alternative arrangements had been made to provide residents meals during this time. Two bedrooms have had new carpets. Two bedrooms have been redecorated and a further three bedrooms were identified for redecoration. Some new bedroom furnishings, bed linen and curtains were purchased. Nonslip flooring has been laid in bathrooms and toilets, new toilet seats were fitted and the ground floor toilets were redecorated. Chairs were being replaced in the lounge and the conservatory chairs were recovered. New tablecloths, crockery and cutlery were purchased. Gravel has been removed from the DS0000065918.V290899.R01.S.doc Version 5.2 Page 17 driveway and car parking space and tarmac put down. This has improved access to the grounds for residents. The gardens were well maintained. The inspector toured the building. All areas seen were clean. Supplies of disposable gloves and aprons were provided for staff use. There are handwashing facilities in all bedrooms, bathrooms, toilets, laundry, sluice and kitchen. Arrangements are in place for disposal of clinical waste. The home has policies and procedures on infection control. Eight staff to date have received infection control training and further training was being organised. DS0000065918.V290899.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using evidence gathered both during and before the visit to this service. There is a stable staff team and suitable carer levels are provided to care for the number of residents. The home has not met the standard for the ratio of staff with care qualifications, but progress is being made. The recruitment process is generally robust, however photographs and statements of medical fitness need to be kept on staff files. An improved range of training was being provided to staff. EVIDENCE: The home continues to provide at least minimum staffing levels of 2 carers on duty during the day and at night. Carers shift patterns are 7.00am to 12 noon, 12 noon to 5.00pm, 5.00pm to 10.00pm and 10.00pm to 7.00am. The manager’s hours are mainly additional to these levels. There are now two designated senior carers to deputise in the manager’s absence. A staff member is designated as being in charge of each shift. There are 42 catering and 28 domestic hours weekly. The manager was aware of the need to increase staffing when there is increased resident occupancy. DS0000065918.V290899.R01.S.doc Version 5.2 Page 19 The majority of staff work part time hours. 18 carers are employed. To date 5 carers have achieved National Vocational Qualifications (NVQ) in care. A further 6 carers have recently commenced NVQ training. A sample of staff recruitment files was examined. A photograph of the staff member is needed on each person’s file. Appropriate information was maintained, for example proof of identification, application form, references from suitable sources, and interview records. Arrangements are in place for all staff to have Criminal Records Bureau (CRB) checks carried out. Staff complete a medical questionnaire, however a statement regarding fitness to do the work is needed. Staff receive a copy of their job description, contract of terms and conditions and the General Social Care Council Code of Conduct. There was evidence of staff undertaking induction training. This training for new staff is usually carried out over 6 weeks. The home uses two training providers. Individual training records and certificates are kept. In the past year staff have been provided with training in moving and handling, first aid, fire safety, health and safety, food hygiene, administration of medication, care planning and guidance on the role of the key worker. Further training was planned on protecting vulnerable adults, catheter care, and infection control. DS0000065918.V290899.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using evidence gathered both during and before the visit to this service. An experienced manager, who is working towards a management qualification, is managing the home. Methods to monitor the quality of the service have been introduced. Residents were very complimentary in their comments about life at the home. The home safeguards resident personal finances. Staff were being provided with regular individual supervision. Management ensure compliance with health and safety requirements. DS0000065918.V290899.R01.S.doc Version 5.2 Page 21 EVIDENCE: Mrs Yvonne Routledge, who has previously worked at the home, returned as the manager in February 2006. She has over 10 years experience working in care of older people with approximately 5 years in a senior capacity. She has completed NVQ Level 3 in care and is currently studying towards achieving the Registered Manager Award qualification. Mrs Routledge has submitted an application to the Commission to be approved as the home’s Registered Manager. The manager has introduced an annual quality development plan that includes resident meetings, surveys and audits to monitor the quality of the service. Mr Humphreys, the home’s owner was currently in the home 4-5 times weekly. He has weekly meetings with the manager on the conduct of the home and these are recorded. The inspector agreed to send a suggested format for monthly reports on the home. All comments received from residents during the inspection were very positive about living in the home. These included “I’ve never been so well cared for”, “They’re all lovely here”, “I’ve settled well” (new resident), “We’re very well looked after”, “It’s a very good home”, “Staff are kind and nothing is a bother”. A visiting relative said the home was wonderful and her mother was well cared for. The District Nurse visited during the inspection. She commented positively on the helpfulness of staff and the homely atmosphere. 10 residents completed Commission for Social Care Inspection surveys. Each said they had received a contract. 8 said they received enough information about the home before moving in, and 2 said they had not. Each said they always or usually received the care and support they need, including medical support, that staff listen and act on what they say, and staff are available when they need them. They confirmed activities are arranged that they can take part in. All said they always or usually like the meals. Residents indicated they know how to make a complaint. Each said the home is always fresh and clean. Additional comments were made as follows: “The staff cannot do enough for me, they are all good and kind. They always have time for to listen. Even if they are busy with other residents they still come to see me. If I am not very well I tell the staff and the doctor comes. We play bingo and sometimes a singer comes. I enjoy all my meals. I don’t make any complaints, I would speak to Yvonne (Manager), she is a lovely person. The home is very clean. My room is always clean. We have a very good cleaner. I am very happy here and I am glad I came”. “I am happy and well cared for”. 4 relatives/visitors completed Commission for Social Care Inspection surveys. All said they are welcomed into the home, can visit in private, are kept informed of important matters affecting their relative/friend, and are consulted DS0000065918.V290899.R01.S.doc Version 5.2 Page 22 about their relative’s care. Each indicated there was always sufficient staff on duty. All were aware of the home’s complaints procedure. All said they are made aware of forthcoming inspections and the availability of inspection reports. Each was satisfied with the overall care provided. Additional comments were made as follows: “I visit every other day and get on with all staff very well. If I did see something I didn’t approve of I would tell them, but it has not been so up to now nearly 6 years my mother has been there”. “I have been very happy with Denecroft and its’ staff who are a very friendly and capable team”. “Recently taken over by a new owner who is personally involved with the day to day operation which adds to the efficient running of the home”. Reponses and comments from surveys were relayed to the manager. Resident personal finances were checked at the inspection in April 2006. These were appropriately recorded and included two staff signatures to transactions, as previously recommended. The manager has introduced a schedule of individual supervisions for staff. The manager and two senior carers were taking responsibility for providing care staff with supervision at least 6 times a year. The home has maintenance and servicing arrangements for amenities and equipment. Staff receive health and safety training and all were up to date with training in safe working practices – fire safety, moving and handling, food hygiene, and first aid. As previously stated training in infection control is being arranged for more staff. Risk assessments and plans are devised according to individual resident’s vulnerability. A range of risk assessments associated with the environment and tasks/activities were in place. These had been reviewed in recent months. The fire logbook was examined. All fire safety checks, tests and instructions to staff were up to date and being carried out at the correct, or in excess of the required frequency. Accident reporting was suitably recorded and the manager was ensuring follow up entries were added. DS0000065918.V290899.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 3 DS0000065918.V290899.R01.S.doc Version 5.2 Page 24 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 OP29 Regulation 19, Schedule 2 Requirement Staff recruitment files must include photograph and statement of medical fitness. Timescale for action 27/09/06 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 OP28 Good Practice Recommendations The home should continue progress towards meeting the standard of at least 50 of care staff to achieve NVQ Level 2 or equivalent qualification. DS0000065918.V290899.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: 0845 015 0120 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 DS0000065918.V290899.R01.S.doc Version 5.2 Page 26 - 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!