Inspection on 13/06/07 for Dunelm

This inspection was carried out on 13th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

Dunelm 13/02/06

Dunelm 17/05/05

Dunelm 17/11/04

Dunelm 08/06/04

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 Dunelm 115 Dunelm South Durham Road Sunderland SR2 7QY Lead Inspector Miss Andrea Goodall Key Unannounced Inspection 13th and 29th June 2007 10:00 Dunelm DS0000040712.V336621.R02.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Dunelm DS0000040712.V336621.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Dunelm DS0000040712.V336621.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dunelm Address 115 Dunelm South Durham Road Sunderland SR2 7QY 0191 522 7398 P/F 0191 522 7398 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) Tyne and Wear Autistic Society Mr Michael John Ross Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Dunelm DS0000040712.V336621.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th February 2006 Brief Description of the Service: Dunelm is a family-sized house that is registered as a care home for 4 young people with Autism Spectrum Disorder. The service is operated by Tyne & Wear Autistic Society (TWAS), which also operates a number of other similar smaller homes in the nearby area. The home is a semi-detached 1930s house on a main road near the City centre. The home has a short driveway, and a back garden. On the ground floor there is a comfortable lounge, a dining room, a large conservatory/sun room, and one bedroom. There is also a family-style kitchen, a staff sleep-in room that also doubles as an office, and a small utility room. On the first floor there are 3 good-sized bedrooms, 2 of which have en-suite bathrooms. There is a third bathroom adjacent to the other bedroom. Dunelm is decorated and furnished to a very good standard in a style that suits the age and tastes of the people who live here. The home is not intended to provide accommodation for people with physical disabilities. There is a small step into the home at the front entrance. However a portable ramp could be provided if necessary for visitors with mobility needs to access to the ground floor only. The weekly fees range from £1619 to £1986. Dunelm DS0000040712.V336621.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit took place over one day and evening. The home was only told about the visit the night before, and this was to make sure that people would be at home for the visit. A couple of months before the inspection the manager sent back some information about the home. Three of the four people who live here filled in picture comment cards about their home with help from staff. Two relatives also sent in comment cards. During the visit the inspector talked with the manager about how the home helps the people who live here, and about staff and records. Most parts of the house were looked at, and two people showed the inspector their bedroom. The people who live here have Autism Spectrum Disorder. This makes it very hard for them to say what they think of the service they get at this home. There have been no complaints or concerns about the home since the last inspection. In this report Tyne and Wear Autistic Society will be called ‘TWAS’, and the people who live at Dunelm will sometime be called ‘residents’. What the service does well: TWAS makes sure that the home is going to be able to care for the people before they move here. Staff keep good records about how residents are learning to do things for themselves, such as making meals, ironing and looking after their own money. People here go out to lots of different activities that they enjoy. People are supported to make sure the activities are not against their religion. One relative said, “Dunelm offers excellent facilities and care.” There are good choices of meals. People go shopping and make the meals that they like, with help from staff. Staff help people to make meals that are important to their religion. All of the house is nicely decorated. There are lots of lounges and bathrooms for 4 people. The staff have lots of training to make sure that they know how to help people in the right way. Dunelm DS0000040712.V336621.R02.S.doc Version 5.2 Page 6 The manager and TWAS make sure that the home is run in best way for the people who live here. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Dunelm DS0000040712.V336621.R02.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 Dunelm DS0000040712.V336621.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home provides clear information so prospective residents can make an informed choice about whether to move here. Comprehensive assessment procedures ensure that only those residents whose needs can be met are offered a placement at Dunelm. EVIDENCE: The Service Users Guide includes a brief brochure that is written in plain English, which gives specific information about the house, the service, and the activities. It now includes photographs of residents taking part in the daily domestic tasks and relaxing in the house. In this way any prospective new residents have clear information about Moorpine before they visit to see if it would suit them. TWAS has clear written guidelines about referrals and assessments. Before they move here, the needs of a prospective resident are assessed by social and health care professionals. The prospective resident, their relatives and TWAS staff are also fully included in making a decision about whether the home could meet people’s needs. People who are new to TWAS services have at least a one-week trial stay at a TWAS home as part of the assessment process. Dunelm DS0000040712.V336621.R02.S.doc Version 5.2 Page 9 The four young men who live here had already been receiving TWAS educational or residential services for some years prior to moving here. In this way their care has been subject to continuing assessment and review to ensure that their needs are met. Dunelm DS0000040712.V336621.R02.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clear care planning means that residents are supported towards achieving their goals. People are supported so that they can make their own decisions, and take acceptable risks as part of an independent lifestyle. EVIDENCE: There are individual care plans for each of the young people living here. These include comprehensive details of each person’s abilities and strengths, as well as their background, cultural/religious beliefs, and a baseline assessment of their support needs. From the assessments, the care plans set out a small number of specific independent living goals (smart targets) for each person in 3 main areas of their lives - domestic, leisure and self- development. For example, doing their laundry, making a purchase, and making a cup of tea and sandwich. Dunelm DS0000040712.V336621.R02.S.doc Version 5.2 Page 11 The plans include detailed instruction to staff about the level of support each person needs with their goals. There are clear daily records about each residents progress and how staff can further support them towards independent living. Residents may sometimes be present when staff are completing their care plan records. Due to their Autism most people find it difficult to understand the care plans, but there is a dated record to show when the care plan was verbally explained to each resident and whether the resident can understand their care plan or not. For example one person can understand the goal when he is actually engaged in the activity, but cannot connect it to the written care plan. Staff stated that the care plans do not contain symbols or pictures, as residents do not understand the wider concept of the care planning process. However staff do use pictures when engaged in the activity, such as laundry, to teach residents to follow the correct sequence of tasks. The home also uses pictorial daily schedules so that each person can make sense of the pattern of their day. The people who live here use speech, gestures and bodily expressions to communicate their likes and dislikes. They are encouraged and enabled to make their own choices and decisions, such as their appearance, menus, leisure activities, and holiday destination. The manager demonstrated the use of the home’s computer in supporting people to have voiced-information to support and encourage their communication skills. The manager indicated that speech and language therapists are to also to be involved in developing new communication tools to support the people who live here. The home has a Participation of Service Users policy that supports residents’ rights to be involved and included in making decisions about the home. Residents have a meeting about every month where they are encouraged to make suggestions and reach group decisions. For example, choosing new furnishings for the house from catalogues. The people who live here are supported to take acceptable risks as part of an independent lifestyle. There are risk assessment records in place about activities that people carry out that might incur an element of risk, such as horse riding, using a locked bathroom, and preparing meals. It is good practice that these records have been sent to parents and the relevant Social Workers, and are reviewed at least annually. Some risk assessments are signed by the resident. Dunelm DS0000040712.V336621.R02.S.doc Version 5.2 Page 12 Recently all TWAS small homes have been fitted with a new door security system, which is linked into the homes’ fire alarm system. This allows the main entrance doors to be locked at all times for security, but the lock releases in the event of the fire alarm system being activated. In this way residents and staff would be able to exit the house in the event of a fire without having to first unlock a door. However this system also means that people cannot access or exit their house without a fob (electronic swipe key). At the time of this visit none of the people who live here had their own fob, and there were written risk assessments in place about this restriction. These risk assessments indicated that individual residents do not have the capacity to manage this risk. However residents have signed this risk assessment. It is not clear whether the signature is to denote that the resident has had this information explained to them, or whether they are consenting to the restriction on their movements. In discussions with the manager it was indicated that they do not have the capacity to understand or manage the risk, and are unlikely to have the capacity to consent to the restriction. Currently this is not made clear on the risk assessment record. Dunelm DS0000040712.V336621.R02.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents can choose from a good range of suitable activities so that they have fulfilling, purposeful occupations that also meet their cultural needs. Residents have good support to keep in contact with family members and enjoy community facilities so that they have opportunities to meet others at social events. The home provides clear information so that residents are supported to understand their rights and responsibilities. Residents enjoy nutritious, healthy meals so their choices, dietary and cultural needs are met. EVIDENCE: Dunelm DS0000040712.V336621.R02.S.doc Version 5.2 Page 14 All the residents attend day services provided by Tyne & Wear Autistic Society. These include vocational courses at the nearby Thornbeck College, such as IT and arts & crafts. Residents also have opportunities to gain practical skills at the TWAS Workshop where they make garden furniture, greetings cards and jewellery, which is sold in the TWAS shop (on a not-for-profit basis). This provides residents with tangible, purposeful outcomes to their daytime occupations. All the residents have a clear pictorial copy of their weekly schedule that they can refer to at any time. These show their activities each day, including the sequence of meals, leisure time, evening activities and bedtime routines. In this way the people who live here have clear information about their activities that meets their communication needs. The home is a family residence and is indistinguishable from other similar properties in the area. It is a short distance from the city centre so residents have a good range of shops and leisure resources nearby. The people who live here make good use of local facilities in the community including shops, sports centres, pubs and cinema. In this way residents are included in the local community. The young men who live here are very active and enjoy a wide range of leisure activities in the evenings and at weekends. These include rock climbing, golf, swimming and bowling. It is very good practice that the home respects and values the different religious beliefs of the people here. One person is fully supported to maintain his Muslim beliefs. Staff ensure that he has his choice of alternatives activities when other residents go to pubs or discos, and also support him with prayer routines. Residents are supported to keep in contact with their relatives by telephone, and some people have occasional short breaks to their family home. Two relatives sent comment cards to the CSCI indicating that they were satisfied with the service provided at The Court. One relative also wrote, “Dunelm offers excellent facilities and care.” Staff encourage and promote conversations with the residents to help their language and communication skills, but also to involve and include them in discussions about their rights. Staff were seen to be friendly, respectful and supportive when talking with residents. Residents can choose to use their own bedrooms for privacy when they are not involved in another activity. Care plans show how residents are supported to read their mail, and have it explained to them in private. Dunelm DS0000040712.V336621.R02.S.doc Version 5.2 Page 15 All residents are all involved in making menus suggestions and are all involved in grocery shopping at a large supermarket so can choose from different ranges of foods. All are involved in preparing meals, snacks and drinks with support from staff. The home has a pleasant dining room where residents and staff dine together. Staff encourage residents to make mealtimes a social occasion where they can talk about their day and discuss their choices of activity for that evening. Meals are nutritious, healthy and suit the age, and preferences of the young people who live here. It is very good practice that the home supports one person to purchase halal and vegetarian options to meet their cultural and religious dietary needs. Dunelm DS0000040712.V336621.R02.S.doc Version 5.2 Page 16 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 and 20. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents receive the right support to access health care services where necessary so that their health and welfare is well met. EVIDENCE: The 4 young men who live here are physically fit and active. They do not require any physical assistance with their personal care needs, but they do need verbal prompts and guidance to wash, shave and bathe. At this time there is one male staff within the staff team, that is the manager. It was stated that the men who live here need some verbal support when at community activities such as swimming, but can get changed independently. The residents are able to choose their own appearance and clothes, though staff support them to ensure that their clothes are suitable for the weather conditions. Dunelm DS0000040712.V336621.R02.S.doc Version 5.2 Page 17 The residents are registered with a local GP practice. They also have access to community dental, optician and chiropody services if required, or can continue to use their family practices if preferred. The home supports residents to access specialist health services if required, for example two residents have epilepsy so have occasional input from neurology services. At this time none of the people who live here have been assessed as capable of managing their own medication although one person is encouraged to manage his own medicated cream. All staff who take responsibility for administering medication have had certificated training in Safe Handling of Medication. There is a list of the designated staff that can manage this. Medication is delivered to the home by a local pharmacy in suitable containers. Medication is securely stored in a locked, alarmed metal medication cupboard away from residents accommodation. Records of the administration of medication are in place and up to date. Dunelm DS0000040712.V336621.R02.S.doc Version 5.2 Page 18 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 and 23. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People have good information so they know how to make a complaint. Staff are trained in safeguarding adults so residents are protected from abuse. EVIDENCE: The home has a clear Complaints Procedure that has been provided to relatives and representatives. There is also a simpler pictorial version for the residents that supports their communication needs. It was clear from minutes of Residents’ Meetings that residents are encouraged and supported to express any comments or suggestions including complaints. Staff were able to describe the various ways that residents might use to express dissatisfaction with a situation, for example by speech, gestures or behaviour. There are no recorded complaints from residents. Relatives also have informal opportunities to raise any comments or complaints during discussions with staff. They also have formal opportunities at annual care reviews. There has been one informal complaint raised by relatives, which related to a resident wearing someone else’s clothes. Staff stated that this situation has occurred as the four young men wear similar styles of clothes. However they acknowledged that it is essential to people’s dignity that they wear only their own clothes. Dunelm DS0000040712.V336621.R02.S.doc Version 5.2 Page 19 All staff receive training in the local vulnerable adult procedures to ensure that residents are protected from abuse. As with all care services for adults in the City of Sunderland, TWAS has adopted the MAPPVA (Multi-Agency Panel for the Protection of Vulnerable Adults) policy and procedures. These are robust procedures for dealing with suspected abuse. All TWAS staff are trained in CALM (Calm Aggression-Limitation Management) and new staff will receive this training. This is a method of physical intervention that requires minimal restraint, and is used only to prevent harm to the resident or to others if residents need support to manage their behaviour. This method is approved by the BILD (British Institute of Learning Disabilities) and ensures that all TWAS staff can present a consistent, safe approach when supporting a resident in this way, in any of the TWAS services. Intervention records show that there have been only two occasions where residents needed support to manage their behaviour. Intervention records are kept in bound books with numbered pages and clearly detail any triggers and the intervention used to support the resident. These mainly relate to the use of diversion, and time and space for the resident to regain control of their own behaviour. Dunelm DS0000040712.V336621.R02.S.doc Version 5.2 Page 20 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 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People here live in very good quality accommodation that is homely, comfortable, safe and clean. EVIDENCE: Dunelm is a detached family house that provides a very good standard of accommodation and furnishings for the people who live here. All areas of the home are decorated to a very good standard, in keeping with the age of the residents. There is a small driveway to the front of the home and a good-sized rear garden. Since the last inspection the manager has been supporting the residents to be more involved in maintaining their back garden and has supported each to person to plant a different fruit tree here. Dunelm DS0000040712.V336621.R02.S.doc Version 5.2 Page 21 The home provides safe, homely accommodation for the people who live here. TWAS has its own maintenance team that visits the home on a weekly basis to carry out fire tests and to address any minor repairs. In this way any items can be addressed quickly so the home remains very well maintained. There have been no significant changes to the house since the last inspection. During this visit the sealant around two of the three baths was perished. There are cracks to the ceiling on the first floor landing, which has been reported for attention. Residents are supported by staff to manage the household tasks within the house. Staff support them to manage their own laundry. The home has a small, separate utility room off the conservatory. This is satisfactorily equipped for a home of this size. All staff receive training in infection control. All areas of the home examined were well presented, and very clean. Dunelm DS0000040712.V336621.R02.S.doc Version 5.2 Page 22 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 competent so residents receive an effective service. TWAS uses robust recruitment practices to ensure that residents are safeguarded from unsuitable staff. EVIDENCE: Currently the staff team consist of the manager, deputy manager, 1 senior and 2 support workers. Three staff have attained the NVQ level 3 (a care qualification) and one other staff is training towards this qualification. One new staff will receive induction and foundation training that will lead to NVQ training later this year. In this way the home aims to provide a qualified staff team. There are at least two staff on duty (including one senior support worker) at the times that the four residents are at home. Staff carry out sleep-in duties so that there is one staff in the house overnight. Dunelm DS0000040712.V336621.R02.S.doc Version 5.2 Page 23 The two relatives who sent in comment cards indicated that they are kept informed by staff of important matters and feel that there are sufficient staff to support the people who live here. One relative also wrote, “The staff have worked hard and have made a huge difference to our son’s lifestyle.” There have been a couple of changes within the small staff team. These include transfers of existing staff from other homes who were already familiar with the people who live here, and one new appointment. TWAS operates very thorough recruitment and selection procedures. Staff are only employed after satisfactory references and police checks have been received, and this ensures the protection of the people who live here. TWAS promotes a comprehensive equality and diversity policy for all those involved in its services, which includes equal opportunities protocols for its staff. All staff receive Autism Focus training, which is specific training to support them to understand the needs of the people with autism. There is an individual learning plan for each member of staff that identifies any training that they need and a record of all training courses that they have attended. It is evident from records and discussions with staff that TWAS is committed to staff training so that residents receive support from a welltrained, competent staff group. Dunelm DS0000040712.V336621.R02.S.doc Version 5.2 Page 24 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 excellent. This judgement has been made using available evidence including a visit to this service. Residents and staff benefit from a well managed, well organised service. Systems, procedures and practices promote safety and welfare so residents are safe. EVIDENCE: Since the last inspection the former acting manager has been appointed as the manager and been successfully registered by the CSCI. He has worked for TWAS for some years and has attained NVQ level 4 and the Registered Managers’ Award, which are suitable qualifications for a manager of a care home. Dunelm DS0000040712.V336621.R02.S.doc Version 5.2 Page 25 There are clear lines of accountability and management support within the TWAS organisation. In this way the residents, and staff, benefit from a well managed service. TWAS has a comprehensive quality assurance processes in place to review the service, and these includes the views of the residents (and their representatives) through their annual reviews and Residents’ Meetings. Pictorial questionnaires are also given to residents from time to time for them to indicate their likes and dislikes about various aspects of the service including staff, other residents, menus, activities, and the house. There are monthly visits to Dunelm by an external consultant (on behalf of the Provider) who seeks the views of residents and staff, and reports back to the organisation and CSCI on their findings. Staff training records demonstrate that all staff receive statutory training in all health & safety matters. There are up-to-date records of health & safety checks in the house, for example hot water temperature checks. All staff receive in-house fire instruction every 3 months, and all residents take part in a monthly fire drill to help them understand what to do in the event of a fire. Dunelm DS0000040712.V336621.R02.S.doc Version 5.2 Page 26 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 3 23 4 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 X 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X X 2 LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 x 3 X 4 X X 3 X Dunelm DS0000040712.V336621.R02.S.doc Version 5.2 Page 27 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. Standard Regulation Requirement Timescale for action 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 YA9 Good Practice Recommendations Where risk assessment records show that a resident lacks the capacity to manage a risk, for example use of a fob key for the front door, the record should make clear whether or not they have the capacity to consent to the agreed limitations outlined in that risk assessment. The sealant to two baths should be replaced to prevent leaks, and the cracks to the landing ceiling should be addressed. 2. YA24 Dunelm DS0000040712.V336621.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South Shields Area Office 4th Floor St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Dunelm DS0000040712.V336621.R02.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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