Inspection on 15/01/07 for Fenwick Close (2)

This inspection was carried out on 15th January 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fenwick Close (2) 18/07/05

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 Fenwick Close (2) Lichfield Road Sunderland SR5 2AH Lead Inspector Mr Lee Bennett Key Unannounced Inspection 15th January 2007 10:00 Fenwick Close (2) DS0000062831.V299131.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 Fenwick Close (2) DS0000062831.V299131.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. Fenwick Close (2) DS0000062831.V299131.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fenwick Close (2) Address Lichfield Road Sunderland SR5 2AH 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) 0191 5537180 Council of City of Sunderland Mrs. Lynne Ryan Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Fenwick Close (2) DS0000062831.V299131.R01.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 2 Fenwick Close is care home, providing personal care for up to 3 people with a learning disability. Nursing care is not provided, but inreach nursing 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 the city centre. The home is near to local public transport links and facilities such as a 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 (2) DS0000062831.V299131.R01.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 one day in January 2007 and included a scheduled announced site visit. The inspection included a separate look at a pre inspection questionnaire and comment cards received from a service user. The care experienced by a service user was ‘case tracked’ (this is where the inspector focuses on the service provided for individual service users) and time was spent 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 Senior Residential Officer were spoken with. Due to the communication needs of the service user it is difficult for them to make direct comments on the quality of care received, and therefore there are no specific comments quoted 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. They are also informed from evidence received through the inspection of other homes that are part of this group, and which share the same registered manager. What the service does well: Staff work to help create a pleasant and calm atmosphere in the home. Staff in the home are experienced, knowledgeable and work well to help and encourage the service user to access community services and facilities where possible, and to promote an active lifestyle. Staff are innovative in meeting the needs of the service user and work in a relaxed, confident, competent and positive manner. There is a shared vehicle available to help the service user to get out and about. Relatives and visitors are made welcome in the home and their requests and needs accommodated. Visits can be conducted in private, and relatives are kept up to date about service user’s progress. The service users needs are clearly detailed, and their records kept up to date. Staff demonstrate a good understanding of the service user’s 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 (2) DS0000062831.V299131.R01.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 (2) DS0000062831.V299131.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 Fenwick Close (2) DS0000062831.V299131.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): 2 and 3. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. 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 the service user’s needs to an excellent standard. EVIDENCE: The care of a service user was ‘case tracked’. This person was admitted to the home some time ago. This person had a care managers’ (social workers’) assessment undertaken prior to their admission and 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. Fenwick Close (2) DS0000062831.V299131.R01.S.doc Version 5.2 Page 9 From the case file 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 the 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 service user’s specific and specialist needs, such as those relating to medication and personal care support. Further advice is available from specialists within the Social Services and from the Community Learning Disability Team. For example, a speech and language therapist and members of the community learning disability nursing team provide on-going support in the home. Those people who commented are satisfied with the overall care provide at 2 Fenwick Close. Fenwick Close (2) DS0000062831.V299131.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 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service user’s 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. The service user is, as far as is practicable, consulted on and participate in the life of the home to a good level. He is supported to make decisions and where these are taken by others these are documented and based on sound multidisciplinary arrangements. This can help in the development of an inclusive service for those living there. The service user is supported to take risks within a planned framework 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 improved access to community facilities and activities. Fenwick Close (2) DS0000062831.V299131.R01.S.doc Version 5.2 Page 11 EVIDENCE: The service user who was case tracked has a personalised care plan file that follows a standardised format. It is 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) involves the whole team, relatives and other professionals. They 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. The service user’s needs are reviewed frequently, 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 the service user case tracked, these plans of care accurately mirrored the needs observed by the inspector. Care plans are supplemented by a photo-diary that provides evidence of achievements made, and also acts as a communication aid wit relatives. The communications skills and needs of the service user ‘case tracked’ means that staff often have to interpret their choices, and need to understand the meaning of their behaviour. Throughout the inspection, staff were observed to clearly discuss and explain planned routines and activities. Since moving into the home staff have encouraged positive communication, resulting in the service user being encouraged to use an increasingly wide vocabulary. Decisions affecting day-to-day choices and about the activities the service user participates in, particularly outside the home, are taken by a multi disciplinary team. However, the staff team working at Fenwick Close will prepare options for discussion that are based on improving the scope of activities undertaken, underpinned by a desire to improve this service user’s wellbeing. Staff will take the time to listen to the service user, and have a good understanding of their preferences and the way that they express their feelings, choices. Staff have to be very observant of what are often very subtle comments and gestures. 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 (2) DS0000062831.V299131.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, 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. The staff team work in an excellent way to promote the service user’s personal development. This can contribute positively to the service user’s wellbeing and promote a more interesting and stimulating lifestyle. The service user is assisted, to a good degree, to lead active and fulfilling lifestyle by the staff team working to develop a regular community presence, and by appropriately accessing a range of community services and facilities. This will assist in them leading a full and enjoyable life. Personal relationships and friendships are supported to a good level, which helps ensure involvement in family life. The service user’s rights are respected and routines in the home are developed around the service user’s needs to a good level. This can help to promote and encourage the service user’s choices and preferences. Fenwick Close (2) DS0000062831.V299131.R01.S.doc Version 5.2 Page 13 The service user is offered and receives a menu that is planned to meet their needs and preferences. This can help contribute to their general health and wellbeing. EVIDENCE: On the day of the inspection, the service user ‘case tracked’ was being supported, by staff in activities within and out of the home. The service user is also assisted to have trips out and to a range of venues. For the service user 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. These activities are well planned. A photo diary is kept as a record of these activities and to log the progress made by the service user and staff team. The service user is helped to maintain their family relationships. Relatives and friends are able to visit the home and offered privacy during these times. 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 and conduct towards staff and guidelines on how staff respond in different circumstances is outlined in their care plans. Staff also receive relevant training, for example on how to deal with difficult situations. The service user has specific dietary choices, with meals having to be presented in a specific way. This is outlined within their care plans. The service user’s skills are promoted and supported. There is a record kept of the meals planned and provided. Meals are normally taken within the dining room. On the day of the inspection, staff were observed to share their meal with the service user, enabling them to provide support and assistance in a discreet and positive manner. Fenwick Close (2) DS0000062831.V299131.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 using available evidence including a visit to this service. The service user receives personal support appropriate to their needs and preferences, to a good standard, which can help to ensure their privacy and dignity is respected. The service user’s 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 the service user, and are managed in a good and a safe manner. Levels of trained staff who support this task are adequate. EVIDENCE: The service user has their personal care needs outlined within their case file. 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 (2) DS0000062831.V299131.R01.S.doc Version 5.2 Page 15 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. Secure locked storage has been installed for the service user’s medications, with separate storage of internal and external medicines. 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. There are clear procedures in place to guide the use of certain medicines, such as needed on an ‘as and when required’ basis. A sample signature list is in place to identify what staff were responsible for each medication administration. Due to their levels of need, the service user is 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, although some staff still need to do this, and this is a requirement of this inspection. 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 (2) DS0000062831.V299131.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 good. This judgement has been made using available evidence including a visit to this service. Staff aim to understand the service user’s views. These 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 the service user is protected from abuse, neglect and self-harm in a good manner. EVIDENCE: A complaints procedure is available within the home, although due to their needs it would be difficult for them to make direct comments about the care and services received. The procedures do allow others to complain on the behalf of service users, and therefore a record of complaints and suggestions is maintained. None have been documented over that past year and none have been referred to the Commission. Staff have to be mindful of the service user’s behaviour and other means of communication as a means to gauge their feelings. Fenwick Close (2) DS0000062831.V299131.R01.S.doc Version 5.2 Page 17 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, and where necessary these procedures have been adopted appropriately. The service user is further protected by clear guidance, training, reporting arrangements and external scrutiny in respect of physical interventions arrangements. Fenwick Close (2) DS0000062831.V299131.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 using available evidence including a visit to this service. The service user benefits 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. The service user’s bedroom is furnished to a good standard. This can contribute to their comfort in their home. EVIDENCE: 2 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. Fenwick Close (2) DS0000062831.V299131.R01.S.doc Version 5.2 Page 19 Domestic type laundry facilities are provided, and each bedroom has it’s own en-suite bath or shower. Fenwick Close (2) DS0000062831.V299131.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): 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 excellent 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. The service user is 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. The service user benefits from a well supported and supervised staff team. This can ensure that staff members are managed in a way that is service user centred, that contributes to planning for training, and that manages staff performance. Fenwick Close (2) DS0000062831.V299131.R01.S.doc Version 5.2 Page 21 EVIDENCE: The service user at 2 Fenwick Close needs staff assistance to meet many of their personal care needs. Staff support is also needed when accessing community facilities, with catering, and with medication. There is always at least two members of staff present within the home during the day and 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 call upon a designated experienced staff member for additional support if necessary. The examination of a sample of staff records and confirmation by the Registered Manager indicated that staff are only employed in the home after sufficient background checks have been carried out, which help determine their suitability to carry out their role. These checks include the receipt of a Criminal Records Bureau ‘disclosure’, two written references, and confirmation of physical fitness. Staff receive a range of training, relevant to the needs of service users, health and safety, and to care in general. Specialist health and social care support to help the service user 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. Two thirds of the staff team are qualified to NVQ level 2 or higher. Staff receive regular, structured supervisions from their line manager in excess of six time a year. Areas discussed and recorded include their work progress, training needs, and work objectives. Fenwick Close (2) DS0000062831.V299131.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, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service user benefits 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 the service user. This can contribute to the health, welfare and security of service users. Fenwick Close (2) DS0000062831.V299131.R01.S.doc Version 5.2 Page 23 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. She is supported by an experienced senior support worker, based in the home. 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 service user and visitors at all times and there is an open atmosphere that encourages them to let their views be known. The service user is involved in 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 have an associated COSHH data sheet available, but this file would benefit from pruning and indexing to make it more accessible. Fenwick Close (2) DS0000062831.V299131.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 4 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 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 3 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 4 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 2 X 3 X 3 X X 3 X Fenwick Close (2) DS0000062831.V299131.R01.S.doc Version 5.2 Page 25 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 YA20 Regulation 13(2) Requirement The registered person must ensure that all staff who administers medication have received, or are enrolled on a course of study to receive accredited training on the safe handling of medicines. This is a new requirement Timescale for action 26/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Fenwick Close (2) DS0000062831.V299131.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South of Tyne Area Office St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Fenwick Close (2) DS0000062831.V299131.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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