CARE HOME ADULTS 18-65
Donna Claire Venture Short Break Service Donna Claire House 6 Seaburn Terrace Seaburn Sunderland SR6 2BZ Lead Inspector
Mrs Elsie Allnutt Key Unannounced Inspection 20th July 2007 09:30 Donna Claire Venture Short Break Service DS0000015747.V349198.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 Donna Claire Venture Short Break Service DS0000015747.V349198.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. Donna Claire Venture Short Break Service DS0000015747.V349198.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Donna Claire Venture Short Break Service Address Donna Claire House 6 Seaburn Terrace Seaburn Sunderland SR6 2BZ 0191 529 3171 NO FAX 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) Miss Geraldine Plunkett Miss Geraldine Plunkett Care Home 6 Category(ies) of Physical disability (6) registration, with number of places Donna Claire Venture Short Break Service DS0000015747.V349198.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 8th August 2006 Brief Description of the Service: Donna Claire Venture is a short break service operated privately by two people, Geraldine Plunkett and Audrey Turnbull. The service provides planned breaks for both men and women with physical disabilities, between the ages of 18 and 65 years, and who are dependent upon carers for care and support. Donna Claire is situated close to the sea front and within easy reach of a range of shops and other services. The house is a large 2 storey detached building with a bungalow annexe within an area of private housing in Seaburn. It has space and facilities to accommodate people who use wheelchairs and provides 5 single bedrooms. There are adaptations and equipment to meet the needs of people with physical disabilities. The aim of the service is to deliver a service as near to a holiday experience as possible, as well as providing a respite period to their carers. During their stay people are supported, by staff to take part in community based activities. A garden and patio is also available for the people using the service. The home has developed a Service User Guide that informs prospective service users about the service and a copy of the recent inspection report is available in the home for anyone to read. The fees charged by the home are £870:00p per week. Donna Claire Venture Short Break Service DS0000015747.V349198.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took 7:00 hours over two days in August 2007. The first day was spent visiting the short break service and the second day was allocated to gather information from the Annual Quality Assurance Assessment (AQAA). However, due to the managers other commitments this document was not submitted to CSCI within the timescale allocated therefore was not used for the purpose of this inspection. The people who use this service prefer to be referred to as guests rather than service users. This will be respected throughout this report. The views of four guests and five members of staff were sought on the day. As not all of the guests have verbal communication 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. Several guests were able to give an explicit account of their life while staying at Donna Claire comments made were as follows: “This is the only holiday I get away from my house, I am very, very happy coming here.” “The staff are very nice, this is my first time here, I am feeling happy about the week ahead.” As part of the inspection process a sample of: service users’ and staff files, and the homes records were examined and a tour of the building took place. What the service does well:
The standard of accommodation provided by this service is good. It is well maintained and as a result of effective cleaning routines offers a clean and hygienic environment. The inside walls of the home are decorated with attractive paintings and craftwork, which have been skilfully produced by people who have used the service and friends of the home. These offer an added attraction for people staying at the home, while promoting the skill and abilities of the creators of the work. The gardens that surround the building are well stocked and maintained and provide attractive areas for guests to look on to or relax in. The manager stated that guests and people passing often comment favourably about the abundance of colour in the summer. The walls surrounding the garden currently display a variety of summer flowers.
Donna Claire Venture Short Break Service DS0000015747.V349198.R01.S.doc Version 5.2 Page 6 The friendly interaction of guests and staff create a warm and welcoming atmosphere in the home. One member of staff commented, “We aim to make each guest’s stay as enjoyable as possible.” The staffing ratio at this service is excellent and as a result guests receive a service that meets their aspirations and personal needs. The kitchen/dining area includes a dining table that accommodates both guests and staff together providing a focus where a mixture of serious discussion and light “chatter” combined with positive humour takes place. Here guests are given the appropriate amount of time and support to take part in discussions about the service delivery and any planned activity. It is an area where the rights and equality of the service users are positively promoted. The manager and staff ensure that full information in relation to guests’ care needs is received from the guests, their main carers and other professionals involved in their care, prior to their stay. This ensures that the appropriate resources can be put in place prior to their arrival and the needs of guests are fully addressed in the way that they prefer and are used to. One guest commented, “When I arrived my room was set up the way it is at home.” During discussions with the manager and staff it was established that good relationships have developed between Donna Claire and community health services. Nurse Specialists for example in relation to Parkinson’s and Huntington’s disease have delivered talks to staff about the diseases and have equipped staff with important knowledge and advice which guide them in appropriate care practices that benefit guests. What has improved since the last inspection?
So that guests are aware of the terms and conditions of the short break service they are now given contracts prior the their stay, these also include the cost of the fees needed to be paid by the guest. So that staff have the necessary skill and up to date knowledge about how to appropriately manage guests with feeds via PEG (Percutaneuos Endoscopic Gastrostomy) feeding, a specialist nurse has updated their training in relation to the procedures to be carried out. The service has developed and put into practice a new application form that prospective employees complete when applying for work at this service. As well as other appropriate information clear employment history is now evident. So that guests are not put at risk when medication is being administered all staff who are responsible for carrying out this task have attended accredited training in the Safe Administration of Medication. Donna Claire Venture Short Break Service DS0000015747.V349198.R01.S.doc Version 5.2 Page 7 The manager of this service has addressed all of the recommendations made by the Fire Service during their last visit and in particular in relation to the use of smoke detectors that needed to be fitted in the electricity cupboards. These are now fitted with batteries with a 10year life. The manager has also come to an agreement with the fire officer regarding the lack of intumescent strips fitted around the doors. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Donna Claire Venture Short Break Service DS0000015747.V349198.R01.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 Donna Claire Venture Short Break Service DS0000015747.V349198.R01.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): 2,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Guests are given a contract so that they are aware of the terms and conditions of the short break service and the fees to be paid. Good multidisciplinary preadmission assessments received by the home demonstrate guests’ needs and aspirations and assist the service to make an informed judgement as to whether they can meet these. EVIDENCE: All of the people that use this service for holiday and respite reasons choose to do so. All have a physical disability and live at home with a carer, some nearby but many from outside the area. One person visiting from the outside of the area stated: “This place is absolutely wonderful, I cry when I have to go home.” Another guest who was staying for the first time confirmed that they had visited the service prior to making a decision to stay and said: “My son and I liked what we saw, so I decided to come and stay.” Donna Claire Venture Short Break Service DS0000015747.V349198.R01.S.doc Version 5.2 Page 10 The manager confirmed that as much information about a new guest is sought from the service user, the referring agency and the family/main carer, prior to their stay. A multi disciplinary assessment form a local authority was in place for one person and a full assessment carried out by the home was in place for another who had not been referred through an agency. One guest confirmed that they had been involved in the assessment process and that they are supported with their care needs in the same way as they are by the carers at home. Another said that they had discussed what they wanted to do while on holiday prior to visiting the service and plans were in place for her aspirations to take place. Donna Claire Venture Short Break Service DS0000015747.V349198.R01.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. Each guest has a care plan that; is easy to understand, considers all areas of their lives and demonstrates how they are supported to make choices. Guests are supported to maintain their level of independence while at the same time they are supported to take risks safely in order to achieve their aspirations. EVIDENCE: Care plans for individual guests are written in individual notebooks and include details that guide staff to support guests in their preferred way. One member of staff who has worked at the service for only a few months confirmed that she follows the guidelines written in the care plan when supporting guests and she said: “It is important that we all do things in the same way so that guests receive the same service from everyone in a way that they prefer.”
Donna Claire Venture Short Break Service DS0000015747.V349198.R01.S.doc Version 5.2 Page 12 One guest said: “I like a lie down in the afternoon.” This was confirmed in the care plan. Another guest confirmed that they verbally guide staff to assist them to dress in the clothes that they prefer to wear on a particular day. The care plan confirmed this and it guided staff to assist the guest to dress putting on different pieces of clothing being put on in a certain sequence. Guests often bring personal appliances and aids to the short break service to assist them with mobility. There is clear guidance in the care plans that make sure such appliances and aids are used correctly and safely. For example for one guest different coloured slings need to be used with the hoist for different tasks. The care plan is very clear which coloured sling is used for the task in hand and guidelines guide staff to use the equipment safely. So that the independence of one guest is promoted the care plan includes the action to be taken by the carer to enable the guest to use the home’s passenger lift independently. Explicit daily notes are kept for each guest that are used to adapt care plans, to inform the next shift, or to inform carers at home of a guests health or experience at the short break service. Risk assessments and management plans are in place and demonstrate how a risk is safely managed, for example, regarding the moving and handling of a guest and the safe use of a recliner bed and chair. One guest relaxed in a reclining chair and independently and safely used the remote controls to assist them out. Donna Claire Venture Short Break Service DS0000015747.V349198.R01.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. Although the people who use this service often have complex needs, their right to choice and to live a normal and as active life as possible while staying at Donna Claire Venture, is successfully promoted and fully supported. EVIDENCE: Guests staying at this short break service live a full and active lifestyle while at the same time their individual and sometimes, delicate health needs are addressed appropriately. Daily activities in the home address the diverse and often complex needs of the guests. Staff are allocated in sufficient number to address guests needs and their personal aspirations. Donna Claire Venture Short Break Service DS0000015747.V349198.R01.S.doc Version 5.2 Page 14 Due to the level of the guests’ needs and staffing resources available only four guests were staying at the service. This meant that all had 1:1 attention from staff within the home and when they went out for the day. Staff assisted guests to get ready to go out giving time and attention to whether guests were comfortable in the clothes they were wearing and with their positions in their wheelchairs. Although everyone was going out on a shopping trip together on this occasion the guests described the individual activities they had taken part in the previous day. This included playing bowls and a walk along the seafront. One guest described a night at the theatre in Sunderland where she said: “I was treat like the Queen, it was a fabulous experience.” The manager confirmed that the aspirations of guests regarding what activities they want to take part in while at the short break service are discussed as part of the assessment process prior to using the service. However some guests are not able to say what it is they want to do. In such a case the service offers a choice that they feel the individual will enjoy based on the knowledge of the individual person. These are usually determined by taking note of the individuals’ likes and dislikes Some of the choices given are visits to art galleries, garden centres, the theatre, museums, shops and pubs and restaurants. Guests confirmed that the food served at Donna Claire is always very good, plentiful and very tasty. Staff confirmed that guests’ preferences are taken into consideration and this often determines changes to the planned menu. Records confirmed this. Donna Claire Venture Short Break Service DS0000015747.V349198.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive personal support appropriate to their needs and preferences and in a way that enables their privacy and dignity to be respected. EVIDENCE: The people using the service are temporarily registered with a local GP and District Nurse during their stay at Donna Claire who are called upon if and when needed. The service supports service users to hospital appointments during their stay, only as a special request and if the home is confident that they have all the necessary information. Close communication is kept with the families in relation to health issues of the individual, as well as with the Social Worker and the Community Nurse. When there are concerns all parties are informed. Staff interact with guests sensitively and with respect. Service users confirmed that they direct their preferred terms of personal care. They also confirmed that their dignity and privacy is always respected and care
Donna Claire Venture Short Break Service DS0000015747.V349198.R01.S.doc Version 5.2 Page 16 is taken to ensure that their personal image is considered also and assistance is given to dress with the person’s choice of clothing and style. The manager confirmed that only trained staff administers medication. Individual guests bring their medication in individual dispensing boxes and a list of the medication brought is recorded separately. Clear records are kept of medicines dispensed. Medication is stored following appropriate guidelines. Donna Claire Venture Short Break Service DS0000015747.V349198.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to help protect guests from abuse and to seriously address complaints and concerns about the service. EVIDENCE: Guests confirmed that they know how to complain and they felt that their concerns were listened to and addressed appropriately. A copy of the complaints procedure is available in the home. The manager explained that discussions take place with each guest prior to them leaving to make sure that everything during their stay has been to their satisfaction and whether anything could have been better. The results of such conversations are recorded in individual care files and any issues raised, are addressed prior to the next visit. The home follows the Adult Protection Procedures set by the Local Authority. The manager and staff receive training related to these and this is updated with other mandatory training. Staff were able to discuss the appropriate procedures to take if abuse was observed or reported to them. In addition to this in house training takes place in relation to protection issues and the manager regularly addresses issues in relation to good, respectful care practice, by raising staffs’ awareness of what is acceptable and what is unacceptable practice. Guests confirmed that they are treat with respect at all times.
Donna Claire Venture Short Break Service DS0000015747.V349198.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): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. As a result of effective maintenance and refurbishing programmes, and good cleaning schedules the standard of the environment is good, providing service users with an attractive and homely place to stay. EVIDENCE: The environment that is kept very clean and tidy is generally maintained to a good standard. However there are parts of the environment that are beginning to show signs of wear and tear and in the near future will need to be refurbished. The manager is aware of these areas and intends to address them as budget permits. All areas of the building are attractively decorated and have good quality furnishings. New curtains were purchased for the lounge prior to the last inspection. These are of good quality and coordinate with the other furnishings and are fire retardant.
Donna Claire Venture Short Break Service DS0000015747.V349198.R01.S.doc Version 5.2 Page 19 The lounge is an attractive area for guests to relax in, with views of the sea and the gardens, or to watch TV. Four electric recliner chairs are available and all offer different aids to address different mobility needs. The house is accessible for people who rely on wheelchairs for mobility. Guests move around independently in electric or self-propelling wheelchairs and easily manage doorways. A passenger lift gives access to the rooms on the first floor. The gardens that are attractive are easily accessible out of the main door. The bathroom facilities where a specialised bath and a separate shower facility address the varied needs of the guests are regularly maintained. The manager shared her plans at a previous inspection to refurbish the ground floor toilet with new facilities in the near future. The previous recommendations to replace the window with obscure glass at the same time remains. The home has carried out risk assessments for each person who uses the service in relation to having unguarded radiators and in the event of a risk being identified the radiator(s) in question are covered with soft protection. However it remains a recommendation of this report that radiator covers should be fitted to all radiators. Donna Claire Venture Short Break Service DS0000015747.V349198.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): 33,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Excellent staffing ratios, appropriate training opportunities and supervision, ensures that service users are appropriately supported and protected by a competent and qualified staff team. EVIDENCE: The ratio of staff on duty is excellent and reflects the needs of the guests staying at the time and the activities planned. Four guests were staying at the short break service at the time of the inspection and four members of staff were on duty. This meant that guests, all who used a wheelchair for mobility, received individual attention and were able to take part in the activity of their choice out in the community. Although the service has experienced staffing difficulties this year due to staff leaving and sickness, the service has been organised in a way that has not compromised the service received by guests. Donna Claire Venture Short Break Service DS0000015747.V349198.R01.S.doc Version 5.2 Page 21 The staff team is diverse in experience and skill, some staff have worked at the home for many years and some are new to care. One member of staff is a qualified nurse and waiting to go into a nursing placement. She said: “The experience here has been really helpful towards my planned career. I plan to come back and work at least one day a week.” All staff work well together and show their enthusiasm in their work. One new member of staff said: “ I love working here we receive very good support and they tell you exactly what they expect of you.” The induction training was discussed and staff demonstrated enthusiasm about what they had learned and the fact that they were now working towards NVQ. A good training programme is in place and staff feel confident that they acquire the skills through training to meet the needs of the guests. Staff discussed the needs of the guests with respect and understanding. When observing staffs’ social interaction with guests, their response, and the way they addressed guests’ needs, it was evident that positive relationships develop. Recruitment records confirmed that the service’s robust recruitment procedures are followed. Of the files examined all had completed application forms, 2 references and satisfactory CRB checks in place. Donna Claire Venture Short Break Service DS0000015747.V349198.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): 37,39,42 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 the staff team, provides a service that is well run, safe, and focussed on the best interests of the service users. EVIDENCE: This home is well run by a manager that is competent and consistent in her role. The manager has a teaching qualification, managed the home for fourteen years and has a wealth of experience shared with her business partner, who for many years prior to retirement was a qualified nurse. Although prior to the last inspection the manager had kept up to date with mandatory training there are some areas that currently need to be updated. The manager agreed to address this. Donna Claire Venture Short Break Service DS0000015747.V349198.R01.S.doc Version 5.2 Page 23 The manager has decided to register to complete the Registered Managers Award (RMA) and she is currently applying for funding to do this. The assistant manager who supports the manager in the running of the service is currently working through the RMA and NVQ4 in Care. Although there is no formal Quality Assurance system in place the manager and senior staff monitor the service’s systems daily and record these in the service diary. Service users’ satisfaction of the service provided is recorded in the daily notes and the appropriate action is taken to address the outcome for example care plans are reviewed and modified if needed or events and activities are classed as successful or not. This ensures that the home’s policies and procedures are effectively followed and that the service is run in the best interest of the guests. Health and safety procedures are appropriately followed and recorded and staff work reflecting these. Donna Claire Venture Short Break Service DS0000015747.V349198.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 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 3 36 3 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 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 3 X Donna Claire Venture Short Break Service DS0000015747.V349198.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 YA37 Regulation 9(2)(i) Requirement So that the manager gains the recognised qualification she must register for the Registered Managers Award and NVQ 4 in Care or another relevant qualification. (Timescale of 31/10/06 not met) Timescale for action 31/12/07 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. 3. Refer to Standard YA24 YA24 YA27 Good Practice Recommendations The wear and tear beginning to show throughout the building should be addressed as soon as possible. The manager should ensure the safety of the service users by ensuring a low surface temperature on radiators, for example through the use of radiator guards. The plans to refurbish the toilet on the ground floor with facilities appropriate to the needs of people with disabilities should go ahead, while at the same time it is recommended that consideration is given to replacing the windows with obscured glass. Donna Claire Venture Short Break Service DS0000015747.V349198.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South Shields Area Office St Nicholas Building St Nicholas Street Newcastle Upon Tyne DN1 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
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