Inspection on 25/07/06 for Fairways

This inspection was carried out on 25th July 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fairways 16/08/07

Fairways 01/11/05

Fairways 08/07/05

Fairways 01/03/05

Fairways 03/08/04

Fairways 22/03/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Blenheim House

Prince Bishop Court

Park View (15)

Craigmore House

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

CARE HOME ADULTS 18-65 Fairways Easedale Gardens Wrekenton Gateshead Tyne & Wear NE9 7EE Lead Inspector Mr Steve Tuck Key Unannounced Inspection 25 July 16 August and 27 September 2006 10:30 th th th Fairways DS0000007427.V302925.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 Fairways DS0000007427.V302925.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. Fairways DS0000007427.V302925.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fairways Address Easedale Gardens Wrekenton Gateshead Tyne & Wear NE9 7EE 0191 491 0518 0191 491 0518 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) Dr Vayalil Pillai Mrs Julia Short Care Home 6 Category(ies) of Learning disability (6), Physical disability (2) registration, with number of places Fairways DS0000007427.V302925.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st November 2005 Brief Description of the Service: Fairways can provide personal care for six people who have a learning disability, two of whom may have a physical disability. The service cannot provide for those people who require nursing care. The service is run by Clifford House Homes. The home itself is a large corner detached house which is set in its own grounds. It is located in Wrekenton, an area in the East of Gateshead and is close to local services, shops and a variety of community facilities. The home is near to public transport routes. There is a private and secure garden around the home and a large car park at the rear. The house has a kitchen, a dining room and a large lounge area with bedrooms arranged on first and ground floors. The two downstairs bedrooms are more suitable for those people who have a physical disability. All necessary facilities are provided and are suitable for people who live there such as an emergency call system. Fairways DS0000007427.V302925.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over three days and was a scheduled unannounced inspection. The inspection process involved spending time talking to a number of the people who live in the home as well as the manager and staff. Care staff at the home were also observed while they carried out their duties. A sample of records were examined including care plans and staff duty rotas. A tour of the building took place, which included all communal areas and a selection of service users bedrooms. Additionally, before the inspection, service users completed a questionnaire about what it is like to live at the home. Service users said “I am happy and like living here” “I do lots of things with Fairways” “I am happy here” “I like the staff” The judgements made are based on the evidence available at the time of the inspection. It costs from £590.59 to £856.49 each week to live at this home. Additional charges are made for toiletries, newspapers / magazines, and hairdressing. Items which are included in the cost are listed in the homes terms and conditions. What the service does well: The staff and manager have worked together with service users to make sure that the home can meet the needs of the people who live there. These are written in care plans, which show in depth how service users needs will be met. They have welcomed new people to the home, helped them to settle in and know what staff have to do to support them. Staff help people to have interesting lives, they help make sure that people can take part in activities they like and they help them to find and try new ones. The staff and manager help people to make choices about their lives and support them to be as safe as possible when they want to do something risky or without staff. People living or working at the home get on well together, they looked comfortable and happy, telling jokes, talking about their day and giving their views. There is a good atmosphere at the home where service users and staff get on well with each other, and clearly enjoy each others company One person said, “It’s always nice to come back here – this is my home.” Fairways DS0000007427.V302925.R01.S.doc Version 5.2 Page 6 The manager and staff work well as a team and they talk to each other so that everyone knows how to support people. Almost all staff have been trained and some are taking more training to find out about new ideas and to get better at helping people. The house is comfortable and is decorated and cleaned to make it a pleasant place to live. Service users rooms are private; they can have their own keys and make rooms their own with furniture and possessions if they want to. Some parts of the house have been changed so that it is easier for people to get around or use the facilities and not long ago the gardens were made more private. There were no dangers noticed at this inspection and the manager has taken steps to make sure that all parts of the home are well kept. There is a choice of meals offered, chosen by service users and the food is fresh and of a good quality. And people living at the home said that they like the food. 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. Fairways DS0000007427.V302925.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fairways DS0000007427.V302925.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 2 3 and 4 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. A range of information about what life is like at the home is available to help people to decide if they want to move there. Each service user’s needs are assessed before they move to the home. This helps to make sure that their needs can be met at the home and inappropriate admissions are avoided. EVIDENCE: The home has written information called the service users guide which gives all of the important information that people need to know about the home. This includes information about how to make a complaint and the most recent Inspection report. The manager prefers people to visit the home before they decide to move in, for example by offering visits and overnight stays. Each service user’s needs are assessed before they move to the home either by a local authority social worker and the manager. This is so that the manager can be sure that the home is suitable for meeting the needs of people who are going to live there. The manager also finds out the cultural and Fairways DS0000007427.V302925.R01.S.doc Version 5.2 Page 9 lifestyle needs of people who wish to move to the home to make sure that these can be met. One person ha successfully moved to the home since the last inspection and all of the people who live at the home at present have been properly placed and are able to have their needs met there. Service users are supported and asked their views when someone new is to move into the home. One service user said, “I like living here, when new people come here everybody is nice to them so they are happy here.” Fairways DS0000007427.V302925.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 7 8 and 9 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Each person who lives at the home has a care plan, which sets out their preferences and needs and how they will be supported by staff. This helps to make sure that staffs’ care practice is good. Service users are encouraged to make choices and decisions about their lives and take calculated risks so that they can live as independently as they can. They are able to give comments and help to make changes about the way the home is run. This helps people to have control of the decisions which affect them. EVIDENCE: There continues to be detailed and thorough care planning records in place. These describe the ways that staff are to support the physical, emotional and lifestyle needs of each person living at the home. These are updated by staff every month, overseen by the manager and reviewed every six months or earlier if service users’ needs have changed. Service users are involved in Fairways DS0000007427.V302925.R01.S.doc Version 5.2 Page 11 making and keeping care plans and staff help service users to make choices about how they live their lives. For example daytime, leisure and work choices. Most staff have had training about how to write and maintain care plans which they have successfully put into practice at the home. One service user asked, Have you had a look in my plan?” when she was talking about her life at the home. Service users are treated with respect by staff that currently work at the home. Relationships between service users and with staff are relaxed, friendly and informal which helps people to feel comfortable. Staff and the manager at the home help service users to take measured risks, for example to do something on their own or with less help from staff. Some people are travelling by themselves, spending time in the garden or around the house without staff and some people are thinking about going to the shops alone. Records are kept of all risks which service users take and this includes the actions that staff have to do so that service users are as safe as possible. These are recorded in care plans and agreed with each service user as well as key-worker, social worker and family members where this is needed. People living at this home give staff and the manager their views about the service and they are respected by staff. For example by following their wishes when they go into bedrooms or private areas. Staff also listen to service users views and are courteous to them. The proprietor has also started to carry out his legal duty to visit the home on a monthly basis to make sure that the service is being run properly and ask service users their opinion. Fairways DS0000007427.V302925.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11 12 13 14 16 and 17 Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are assisted by staff to have active and interesting lives by finding and getting to different opportunities in the local and wider community. This assists them to lead a full and enjoyable life. People who live at the home are respected, and routines are flexible. This can help to promote service users’ choices and preferences. Service users are supported to keep in contact with their relatives and friends and are able to spend time together outside of the home. The food is of good quality and sufficient to meet the needs of service users. This helps them to enjoy meals and stay healthy. Fairways DS0000007427.V302925.R01.S.doc Version 5.2 Page 13 EVIDENCE: All service users have active lifestyles, with their own routines and activities many of which occur outside of the home. Some service users described what they did during the day and said that they had the option to do things that they found interesting or go to places for example day services where they meet up with friends. One service user wrote, “During the day we can chose what to do.” The staff are skilled at helping people to organise themselves, they help service users to make decisions as well as offering choices, and helping them to organise their commitments. Staff at the home were very busy planning how individual support for service users was to take place so that all of their choices and event commitments could be met. Staff are helpful and use their skills to find out about activities which are taking place and had making sure that support and transport is available for those people who wanted to take part. Photographs of service users taking part in activities and during visits are displayed and service users talk about these experiences. For example celebrations and visits. Staff help service users to keep in tough with friends and relatives. One person said, “ I like to write letters to my family.” Service users have the opportunity to use the ‘Links in Gateshead’ befriending scheme run by the local authority and can find employment opportunities and can get support if this is what they wish to do. Other people have taken college courses where they have an interest or skill and several certificates are displayed which show their success and commitment. Service users have recently returned from a holiday where they paid for their own expenses. This was enjoyed by everyone. Several choices of meals are offered at all times and service users help to plan their meals each taking a turn in listing their preference and they are also involved in the preparation of meals at the home. Attempts to offer a balanced diet whilst still responding to service user choices were noted. Some people need to eat food which helps them to stay healthy for example if they have a medical condition. For these service users special diets and food supplements are made available and staff help by monitoring their weight which is then recorded. Staff join service users at mealtimes to offer support and assistance where needed. Mealtimes are pleasant sociable events at the home where people meet, talk, tell jokes and exchange views and experiences. And enjoy each other’s company. Fairways DS0000007427.V302925.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 and 20 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users health care needs are identified and arrangements are made to help ensure they are promoted and met. Staff will also advocate, or seek additional advocacy support, to ensure that each service users’ rights of access to health care services and treatment are met. Systems for storing and administering service users medication are in place to ensure that service users get the treatment which they have been prescribed. EVIDENCE: Detailed records of service users healthcare needs are available in care plans which show that these are supported by staff who look out for possible illnesses. For example if a service user has delicate skin, ways of working are agreed amongst all staff so that treatment takes place and then continue to be monitored. All service users have a General Practitioner who can also refer to other health care professionals when this is required. The manager takes action to make sure that service users can get the healthcare treatment which they need and Fairways DS0000007427.V302925.R01.S.doc Version 5.2 Page 15 make sure that service users can make informed choices about how their health. Staff have carried out some thoughtful work where they have needed to meet the healthcare needs of service users who do not use language to communicate. Any personal care or discussion is carried out in private with staff encouraging service users to be discrete where this is required. Due to their levels of need, service users are not able to administer their own medicines, and designated staff therefore assist in this area. Staff at the home have undergone training in relation to medication administration. Medication is securely stored and records are accurate which enable checks to be made so that errors are minimised. Fairways DS0000007427.V302925.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Service users and their families can make a complaint if they are unhappy, have a grievance or dispute. They can also give feedback when they are happy with the service. This helps them to have control over their lives and shows that their views are valued. The home has measures in place which should protect service users from being harmed. But these have not been followed which has put service users at risk of being abused. EVIDENCE: There is a thorough complaints procedure which tells people what to do if they are not happy. This informs people about who they should make a complaint to and how much time that a complaint will take to look at. On a day-to-day basis most service users were seen to actively express their wishes and views to those staff supporting their needs. One to one time is available for service users where concerns can be talked about and the manager has meetings with service users as a group whenever there are issues to be discussed and service users are willing to take part. Informal discussions take place regularly, usually at mealtimes, where staff explore service users views about the service and their lifestyles. Fairways DS0000007427.V302925.R01.S.doc Version 5.2 Page 17 There has been one instance where a service user was found to have been abused. In this case the manager and staff had failed to make sure that the service users was properly protected and had been left vulnerable to abuse. The measures which should have been in place to protect people living at the home did not work or were not used. The manager and staff did not properly respond to their needs nor did they put proper safeguards in place to protect them. As a result of these incidents the owner and manager have taken a number of urgent actions which have been designed to improve the home so that the vulnerable people who live there are protected from abuse. This has included disciplinary action, staff training, a review of the safeguarding adults arrangements at the home and detailed discussion / supervision of staff by the manager. Fairways DS0000007427.V302925.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are provided with a homely, clean, comfortable environment, which promotes their privacy and independence. Aids and adaptations have been provided to promote service users’ independence and safety. Fairways DS0000007427.V302925.R01.S.doc Version 5.2 Page 19 EVIDENCE: The home has had recent repairs, there is ongoing maintenance and a plan for redecoration and renewal is in place. The home is kept clean by staff who take effective steps make sure that the home does not have any unpleasant smells. Service users are encouraged to keep their own rooms clean and tidy and they are helped by staff when this is needed. The house has been adapted so that all service users can have safe access to the home and gardens without restricting the rights, freedoms or independence. And service users are able to lock their bedroom doors so that they can have privacy. The bedrooms are pleasant areas, which have a range of furniture, and fittings which are comfortable and useful for service users. All service users have decorated their rooms with their items, photographs and keepsake’s. There are enough toilet and bathrooms available, some of which have been changed to help people who have mobility needs to use them. Other changes have been made around the home when this has been suggested by occupational therapists. All service users have areas where they can talk to other people or visitors in private. The staff have agreed ways of working in the laundry which lessens the chance of infection or diseases being passed between people living or working at the home. The home is also inspected by the Fire Prevention Service and overseen the local authority to make sure that risks from an accidental fire are lessened and a safe and healthy environment is promoted for service users and staff. Fairways DS0000007427.V302925.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 33 34 35 and 36 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. There are enough staff at the home to support the people who live there. And they have the skills, training and support from the manager so that they can meet the needs of service users Checks are carried out which helps to make sure that staff are suitable to support vulnerable people before they begin work at the home. EVIDENCE: There are sufficient staff available to meet the needs of service users currently living at the home. This helps service users to have their personal and healthcare needs met and also to be supported when they wish to take part in social, education and employment opportunities. Few staff leave the home so they have longstanding relationships with service users and they are knowledgeable of their personal histories and needs. One service user said, “the staff know me well and know what I like but it’s nice to have a new face every now and again so we get to know them.” When staff and service users meet, they get on well together have positive relationships and clearly enjoy each other’s company. Staff are able to describe the needs of service users, both in terms of their practice and the principles which underpin the service that they give. Fairways DS0000007427.V302925.R01.S.doc Version 5.2 Page 21 Almost all of the staff team have now attained NVQ awards in care at level 2 and a number are taking level 3 courses. And the home’s training record shows that they have received training relevant to their job roles and the specific needs of service users. One member of staff said, “It’s getting harder to get the training we need from training organisations but the manager is always looking into that so we can get onto courses.” Records show that staff working at the home had employment checks carried out before they started working there. Fairways DS0000007427.V302925.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 38 42 and 43 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The manager offers leadership and direction to the staff so that they can consistently meet the needs of service users. The home has all of the policies and procedures required, which help staff and the manager run the home efficiently and for the benefit of service users. The financial viability of the home has not been demonstrated which would give assurance to service users that the home will remain open. Staff and service users are not exposed to any undue health and safety risk at the home. Arrangements to make sure that the service continues to improve and to ensure that service users views are taken into consideration have began to be introduced. Fairways DS0000007427.V302925.R01.S.doc Version 5.2 Page 23 EVIDENCE: The registered manger has many years experience in a variety of care roles as well about four years’ management experience at this care home. From observations and discussions, it is evident that the manager is sufficiently competent and skilled to carry out this role and has demonstrated the capacity to take more training so that she can update and expand her knowledge. She is currently undertaking an NVQ Level 4 qualification, which she plans to complete in the next few months. There are clear lines of accountability within the home and the manager now has agreed support from other managers and the proprietor when this is needed and in particular for emergency situations. The home helps service users to manage their financial expenditure. Detailed records are kept of service users finances and where staff have supported them to make purchases. Some of these are held by the home and were checked to ensure that records were accurate and that these finances were securely held. There were no noticeable hazards apparent at this inspection and the manager has taken steps to ensure that all areas of the home are appropriately maintained so that these are minimised. The proprietor has not yet provided the Commission with details which demonstrate that the home is financially viable however this has been discussed with him and assurances have been given that evidence of financial viability will be made available to the Commission. Although there are measures in place where service users and relatives are asked their views about how the service supports them, the services quality assurance programme has not been fully carried out. Fairways DS0000007427.V302925.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 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 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 3 2 X X 3 2 Fairways DS0000007427.V302925.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 YA18 2 3 YA37 9 24 Standard Regulation 13 Requirement Timescale for action 01/11/06 YA39 4 YA43 25 The manager and proprietor must ensure that service users living at the home are protected from abuse. The manager must have a 28/02/07 qualification at level 4 NVQ, in management and in care. The manager must ensure that a 25/12/06 quality assurance programme is in place and an annual developmental plan for the home can be compiled. (Previous requirement from 01/03/06). The proprietor must submit a 25/11/06 copy of the annual business and financial plan to the Commission. (Previous requirement from 1/4/05) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Fairways DS0000007427.V302925.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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 Fairways DS0000007427.V302925.R01.S.doc Version 5.2 Page 27 - 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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