CARE HOME ADULTS 18-65
Fenwick Close (1) No 1 Fenwick Close Lichfield Road Sunderland SR5 2AH Lead Inspector
Mr Lee Bennett Key Unannounced Inspection 14 and 21st March 2007 13:00
th Fenwick Close (1) DS0000062829.V299129.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 Fenwick Close (1) DS0000062829.V299129.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. Fenwick Close (1) DS0000062829.V299129.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Fenwick Close (1) Address No 1 Fenwick Close Lichfield Road Sunderland SR5 2AH 0191 5493875 0191 5493875 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) Council of City of Sunderland Mrs. Lynne Ryan Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Fenwick Close (1) DS0000062829.V299129.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 7th February 2006 Brief Description of the Service: Number 1 Fenwick Close is care home, providing personal care for up to 3 people with a learning disability. Nursing care is not provided, but in-reach and District Nursing services can be arranged where necessary. It is a purpose built bungalow with level access to all of the accommodation. The home is suitable for people with a physical disability or frailty. There is a large enclosed garden to the rear of the home and shared car parking to the front. The home is situated in a suburb of Sunderland, and is a bus ride or car journey away from central Sunderland. The home is near to local public transport links and local facilities, such as doctors surgery, pubs and places of worship. The fee charged at the home is £0000.00 per person, per week (April 2006 to March 2007) Fenwick Close (1) DS0000062829.V299129.R02.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was carried out over three separate days in March 2007 and included a scheduled unannounced site visit. The inspection included a separate look at a pre inspection questionnaire and comment cards received from service users and their relatives. The care experienced by a sample of service users was ‘case tracked’ (this is where the inspector focuses on the service provided for individual service users) and time was spent chatting with service users and observing life in the home. The premises was inspected as was a sample of service users and staffing records. Service users, staff, the Registered Manager and other Council Officers (responsible for staff recruitment records) were spoken with. Questionnaires were also received from service users’ relative. Due to the communication needs of service users it is difficult for them to make direct comments on the quality of care received by them, and therefore there are no specific comments given by service users in this report. The judgements made are based on the evidence available to the inspector during the inspection and from the information received before and during the site visit. What the service does well:
Number 1 Fenwick Close is a well equipped and furnished care home. There is a pleasant atmosphere and service users and staff get on well. Staff in the home have a range of experiences and backgrounds, are knowledgeable and work well to help and encourage service users to access community services and facilities. There is a shared vehicle available to help service users to get out and about. Staff will also assist service users to speak up for themselves and have a good rapport with them. Regular contact with relatives and other visitors is encouraged and relatives are able to visit in private, kept up to date about service users progress, and are satisfied with the overall care provided. Service users needs are clearly detailed, and their records kept up to date. Staff demonstrate a good understanding of service users needs. The care provider (Sunderland City Council) in liaison with the landlord make sure the accommodation is kept at a high standard through regular cleaning, decoration and maintenance.
Fenwick Close (1) DS0000062829.V299129.R02.S.doc Version 5.2 Page 6 Staff recruitment checks include references and Criminal Records checks. These help to ensure safe recruitment practices are in place. Staff also receive regular, structured supervisions (meetings with their manager), which allow them to discuss issues relevant to service users and themselves. It also means that the staff team is well managed, and that their work meets service users’ requirements first and is focused on their needs. The care provider has a clear policy on equal opportunities. This relates to both care practice and staffing issues. For example, staff recruitment is in part governed by equal opportunities principles. 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. Fenwick Close (1) DS0000062829.V299129.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 Fenwick Close (1) DS0000062829.V299129.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 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 using available evidence including a visit to this service. Prospective service users are given a good level of information about the home to help them and their representatives to decide if the home is right for them. Prospective service users needs are assessed before their admission to the home and are also periodically re-assessed to a good standard thereafter. This can help ensure that the service can be planned in a way that meets service users needs and wishes. The home is able to meet the range of service users’ diverse needs to a good standard. Prospective service users are given good opportunities to visit and ‘test drive’ the service before a final decision is taken as to whether the home is right for them. This can offer service users time to decide if the home is able to meet their needs in a way that suits them. Fenwick Close (1) DS0000062829.V299129.R02.S.doc Version 5.2 Page 9 EVIDENCE: Before moving to 1 Fenwick Close, the service user most recently admitted to the home was given the opportunity to visit the service on several occasions, including a chance to spend time with another service user living at the home, to share meals and to have overnight stays. The care of both service users was ‘case tracked’. This included the needs of a service user who was recently admitted to the home. This person had a care managers’ (social workers’) assessment undertaken prior to their admission. This details their abilities and needs. Staff in the home will also complete periodic re-assessments, which outline personal care, health care, social and psychological needs. From these assessments, plans of care are then developed to guide the practice of staff, which is then translated into the way in which staff deliver care. This is recorded in daily updates Of the case files examined it was evident that their needs are subject to periodic review and re-assessment. Following such an assessment plans of care and risk assessments are developed by ‘key workers’. These mirror the needs observed by the inspector. The needs of each service user are detailed within their personal case files, and they also detail the action taken to meet these needs and progress made. Staff received training and guidance relevant to the majority of service users specific, diverse and specialist needs, such as those relating to health conditions, and medication. Further advice is available from specialists within the Social Services and from the Community Learning Disability Team and Speech and Language Therapists. Those people who commented are satisfied with the overall care provide at 3 Fenwick Close. Fenwick Close (1) DS0000062829.V299129.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 at least once during a 12 month period. 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. Service users’ care plans are in place, and reflect their observed needs (including their cultural needs and personal preference) to a good level. Effective care planning can offer guidance to care staff regarding care practice and ensure consistency where necessary. Service users are, as far as is practicable, consulted on and participate in the life of the home to a good level. This can help in the development of an inclusive service for those living there. Service users are supported to take risks within a planned framework, irrespective of their needs and level of ability. This can help ensure their independence is promoted, balanced against a judgement about any risks involved. This can also help promote an awareness of safety to a good level and ensure equality of access to community facilities and activities. Fenwick Close (1) DS0000062829.V299129.R02.S.doc Version 5.2 Page 11 EVIDENCE: Each service user has a personalised care plan file that follows a standardised format. They are split into a section that summarises areas of need, likes, dislikes and so on. A second section outlines more detailed plans of care to help describe and guide staffs care practices. These plans are developed by key workers (staff who work specifically with an individual service user) and cover a broad range of need areas. These are linked to regular monitoring of some areas such as personal care, behavioural needs, diet, weight and activities, and are then periodically reviewed and subsequently updated. Each service users needs are reviewed annually, or more frequently if needed, where their progress and wishes can be discussed. This documentation highlights each service users’ abilities, strengths, and preferences, as well as areas of need. Staff are also able to comment on and describe service users’ strengths, abilities and needs. For those service users case tracked, these plans of care accurately mirrored the needs observed by the inspector. The communications skills and needs of the service users ‘case tracked’ vary from day to day. Staff occasionally have to interpret their choices, and need to understand the meaning of their behaviour. Staff demonstrated this by explaining the specific needs of service users to the inspector. In addition, following the input of a Speech and Language Therapist, staff now use visual aids (such a picture prompts) and social stories to aid communication and to develop people’s skills. Staff were observed to discuss and explain routines and activities with service users, irrespective of their communication needs. Service users are asked and allowed to make decisions affecting day-to-day choices and about the activities they participate in. Staff were observed to take time to listen to service users, and have a good understanding of their preferences and the way that they express their feelings, choices and when they are making specific requests of staff. Areas of risk are also documented within each service users’ care file, including assessments relating to activities out of the home, behaviours that may challenge the service, mealtimes, and the use of equipment. This can contribute to staff having guidance to enable service users to maintain their independence and access community facilities without being placed at undue risk of harm. A model is used, whereby each risk area is identified, who or what may be harmed is noted, current and additional control measures are documented, and this is then reviewed. Fenwick Close (1) DS0000062829.V299129.R02.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): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are assisted, to a good degree, to lead active and fulfilling lifestyles by having a regular community presence, and by accessing a range of community facilities. This will assist in them leading a full and enjoyable life. Service users are supported to maintain their personal relationships and friendships, to a good level, which helps them to keep in touch, and be involved in family life. Service users rights are respected and routines in the home are flexible to a good level. This can help to promote a flexible service that encourages and promotes service users’ choices and preferences. Service users are offered and receive a varied and well-presented menu that meets their needs. This can contribute to their general health and wellbeing. Fenwick Close (1) DS0000062829.V299129.R02.S.doc Version 5.2 Page 13 EVIDENCE: On both the days of the inspection service users were being supported in activities both within and out of the home. Service users are also assisted to have trips out and participate in a variety of activities, such as a drama class and lunch club. For those service users case tracked, their individual preferences are recorded, and the activities undertaken reflect these preferences, their needs and associated risks. A shared vehicle is available to assist in accessing community facilities. Service users are helped to maintain their family relationships. Relatives and friends are able to visit the home flexibly and a vehicle is available to service users to help them get out and about and to visit friends and relations. Staff have received training on the rights of people with a disability, and human rights awareness forms part of staffs’ NVQ work. The rights and obligations of service users are, in part, expressed and outlined within their residency agreement. Service users responsibilities towards one another, and in their conduct towards staff members are also outlined in their care plans. The beliefs and cultural preferences of service users are recorded and met in ways such as supporting church attendance, providing culturally accepted meals, that also meet service users known preference. Each service users life history is explored, acknowledged and used to help plan activities and care arrangements, for example by understanding the effects that long-term institutional care has had on people. Service users are encouraged to eat a healthy diet, which is outlined within their care plans, for example staff aim to ensure that service users are offered fresh fruit and vegetables regularly and that a healthy body weight is achieved. Service users’ self help skills are promoted and supported. Staffs’ practice reflects the guidance and risk assessments provided. There is a record kept of the meals planned and provided. Meals are normally taken within the dining room, although service users can eat elsewhere if they wish. On the day of the inspection, staff were observed to share their meal with service users, enabling them to provide support and assistance in a discreet and positive manner. Fenwick Close (1) DS0000062829.V299129.R02.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 using available evidence including a visit to this service. Service users receive personal support appropriate to their needs and preferences, to a good standard, which can help to ensure their privacy and dignity is respected. Service users health care needs are identified and arrangements are made to help ensure they are promoted and met to a good degree. Medication arrangements are appropriate for the needs of service users, and are managed in an adequate and a safe manner. EVIDENCE: The service users living at 1 Fenwick Close have their personal care needs outlined within their case files. Their needs are supported and met, where appropriate, in private, and they are encouraged to be independent where possible. Care staff are able to demonstrate, through discussion and observed practice, a good understanding of service users’ needs.
Fenwick Close (1) DS0000062829.V299129.R02.S.doc Version 5.2 Page 15 Regular access to primary and secondary health care services, such as GP, District Nursing, speech therapy and the dentist, is supported. Contact with health care professionals is documented within the service users care records. Although staff currently administer medication for service users, there are plans in place to help a service user to do this more by herself. This is to be done in a staged manner, and with the guidance and support of other professionals, such as the Speech and Language Therapy team. Secure locked storage has been installed for service users’ medications. Printed administration records are kept, which detail when medicines are administered and by whom. A stock balance record is also kept, to help ensure medicines are administered as prescribed and stock appropriately managed. A sample signature list is needed to identify what staff were responsible for each medication administration. Staff at the home have undergone training in relation to medication administration, with others scheduled to commence this later this year. A stock check was undertaken for a sample of medications held in the home. This was concluded successfully, with stocks held corresponding to those recorded. Fenwick Close (1) DS0000062829.V299129.R02.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 good. This judgement has been made using available evidence including a visit to this service. Service users’ views are listened to and acted upon to a good level. This can help contribute to a service user centred service. Steps are taken to help ensure that service users are protected from abuse, neglect and self-harm in a good manner. EVIDENCE: A complaints procedure is available within the home, and informs service users that they can contact the Commission if they wish regarding complaints. A record of complaints and suggestions is maintained, and none have been documented over that past year. None have been referred to the Commission. Service users are aware of who to speak to within the home should they be unhappy about the service they receive. As noted above, service users have varying communication needs, which make it difficult for them to say what they think about the service they receive. Staff therefore have to be mindful of service users’ behaviour and other means of communication as a means to gauge their feelings. Staff have, in the past, received training on the local Adult Protection arrangements, which will help to explain the role of adult protection, and to offer guidance to staff. Written material is available in the home regarding these procedures should staff need guidance in this area.
Fenwick Close (1) DS0000062829.V299129.R02.S.doc Version 5.2 Page 17 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 using available evidence including a visit to this service. Service users benefit from good, well maintained, homely, safe and clean accommodation. This can help promote a positive image for service users, and ensure they remain comfortable and safe. Service users bedrooms are furnished to a good standard. This can contribute to their comfort during their stay at the home. EVIDENCE: 1 Fenwick Close is a purpose built bungalow providing level access and accommodation across one floor. All parts of the home are accessible and therefore suitable for service users with a physical disability. Communal areas consist of a lounge area, and a separate kitchen/dining room. Domestic style furnishings and fittings are provided. Bedrooms have been decorated and furnished in a domestic manner and a regular, planned cycle of cleaning is implemented. Some areas of paintwork have become chipped and marked, and redecoration is planned for this year.
Fenwick Close (1) DS0000062829.V299129.R02.S.doc Version 5.2 Page 18 Domestic type laundry facilities are provided, and each bedroom has it’s own en-suite bath or shower. The home is free from offensive odours and clean throughout. Fenwick Close (1) DS0000062829.V299129.R02.S.doc Version 5.2 Page 19 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): 31, 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. Service users are supported, to a good level, by an effective staff team, deployed in good numbers. This can help ensure their needs are safety met. A good number of staff have obtained qualifications in care. Service users are supported by competent staff who have received good training, relevant to their roles, the purpose of the home and the majority of service users’ needs. This can ensure that service users are supported in a safe manner by staff who have an understanding of these needs. Service users are protected by the home’s recruitment policy and practices, which can help ensure unsuitable candidates do not gain employment in the home. These are implemented to a good standard. EVIDENCE: Service users at 1 Fenwick Close need staff assistance to meet a variety of their personal and health care needs. Staff support is also needed when accessing community facilities, with catering, and with medication.
Fenwick Close (1) DS0000062829.V299129.R02.S.doc Version 5.2 Page 20 There is always at least two members of staff present within the home during the day and one at night, with additional staff present to assist with various activities and appointments, both during the day and evening. Staffing levels are detailed within a staffing rota, which is available for inspection. Staff are supported by an ‘on-call’ arrangement, whereby they can contact a designated experienced staff member for advice and additional support if necessary. The examination of five staff recruitment records and confirmation by the Registered Manager indicated that staff are only employed in the home after a range of background checks have been carried out. These can help determine their suitability to carry out their role. These checks include the receipt of a Criminal Records Bureau ‘disclosure’, confirmation of physical fitness and usually two written references. However, two staff were found to have been recruited (from other council posts) with only one reference on file. All staff must have two satisfactory references, and this is a requirement of this report. In addition, the standard application form that candidates fill in only allows for the last two employers to be listed. This needs to be expanded to ensure candidates provide a full employment history. This is a recommendation of this report, as the provision of this information can help ensure a more thorough picture of a potential staff member is obtained, allowing their experience to be identified and gaps in their record to be discussed. Staff receive a range of training, relevant to the needs of service users, health and safety, and to care in general. Specialist support to help a service user with specific dietary needs has been provided, with ongoing support available as necessary. The manager keeps clear records of the training staff have received, which can assist in the planning of future training for the staff team. Nearly two thirds of the staff team are qualified to NVQ level 2 or higher. Fenwick Close (1) DS0000062829.V299129.R02.S.doc Version 5.2 Page 21 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, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well managed home. Quality assurance systems seek to reflect service users experiences and the views of their representatives to a good degree, which can help ensure the service remains focused on their needs and aspirations. Those records required by regulation are well maintained and available for inspection, to a good standard. This can help staff demonstrate how service users rights and best interests are safeguarded. The home is, to a good standard, free from hazards to service users. This can contribute to the health, welfare and security of service users. Fenwick Close (1) DS0000062829.V299129.R02.S.doc Version 5.2 Page 22 EVIDENCE: The home’s manager has been registered with CSCI and adjudged fit, and has relevant qualifications and experience to undertake her job role. The manager has experience in working within care settings for people with a learning disability. She undertakes training relevant to her job role and the service users’ needs. The home operates a robust self- monitoring system using the Regulation 26 visits carried out by their external managers that are comprehensive, look at all aspects of the home, and make sure the residents are cared for properly. Due to the nature and size of the home the staff talk to the residents and visitors at all times and there is an open atmosphere that encourages them to let their views be known. The service users are involved in regular meetings so that they can be made aware of the way the house is run as a group. The views of families are also sought. Staff also hold meetings to share issues and talk about how they can improve the care they give to the service users. These meetings are recorded clearly and used to help develop plans for the future of the home and development for the service users. At the time of the inspection there were no observed hazards to safety. There is a health and safety policy available to guide staff, and various risk assessments have been developed, both to enable service users to be independent, but also to ensure care and working practices are undertaken in a safe manner. Health and safety checks are also undertaken regularly, including an audit of the building, fire safety checks and instruction, and regular water temperature tests. Cleaning and chemical products all have an associated COSHH data sheet available. An examination of staff training records identified that staff only receive manual handling training on a three yearly basis. As there is a service user who requires regular manual handling it is strongly recommended that refresher training is undertaken on a more frequent basis, to ensure that staff remain up to date on accepted good practice techniques. Fenwick Close (1) DS0000062829.V299129.R02.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 4 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 4 33 X 34 2 35 3 36 X 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 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 3 X 3 X X 3 X Fenwick Close (1) DS0000062829.V299129.R02.S.doc Version 5.2 Page 24 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA34 Regulation Requirement Timescale for action 19/05/07 19(1)(b)(i) The registered manager must ensure that all staff are in receipt of two personal employment references prior to an offer of employment being made. This is to ensure that service users are protected by a detailed recruitment process. 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 YA34 Good Practice Recommendations The registered person should ensure that a full employment history is obtained in respect of all staff candidates who will work with service users. This is to help ensure that service users are protected by a detailed recruitment process. The registered manager should ensure staff attend manual handling refresher courses annually. This can contribute to staff being aware of current good manual handling practices. 2. YA42 Fenwick Close (1) DS0000062829.V299129.R02.S.doc Version 5.2 Page 25 Commission for Social Care Inspection South of Tyne Area Office St Nicholas Building St Nicholas Street Newcastle NE1 1NB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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