Inspection on 15/09/06 for Finchley House

This inspection was carried out on 15th September 2006.

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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Finchley House 15/11/05

Finchley House 14/06/05

Finchley House 26/01/05

Finchley House 03/06/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Finchley House 57 Brandling Street Roker Sunderland SR6 0LP Lead Inspector Mrs Elsie Allnutt Key Unannounced Inspection 15th September 2006 09:30 Finchley House DS0000015744.V309212.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 Finchley House DS0000015744.V309212.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. Finchley House DS0000015744.V309212.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Finchley House Address 57 Brandling Street Roker Sunderland SR6 0LP 0191 510 8448 0191 510 8448 finchleyhouse@c-i-c.co.uk www.c-i-c.co.uk. Community Integrated Care 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) Jaqueline Gannon Care Home 6 Category(ies) of Learning disability (6), Physical disability (3) registration, with number of places Finchley House DS0000015744.V309212.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 2005 Brief Description of the Service: Finchley House was purpose-built as a Residential Care Home in 1993. The property is owned and maintained by Three Rivers Housing and Community Integrated Care delivers the service. The home is built in a residential area in the Roker area of Sunderland and is amongst other housing which pre-dates the home. It is within walking distance of the sea front, shops and local amenities, such as a post office, hairdresser and pubs. The home is currently registered to provide care for 6 adults under 65 years who have learning disabilities and additional physical disabilities. The age range is 25 to 60years. Four of the service users rely on the use of wheelchairs for mobility and are encouraged to be independently mobile around the house. A team of staff support the service users to live a full and active lifestyle and a mini bus owned by the home is available to access the local community. The security of the building has been enhanced through the installing of security lighting. The home has developed a Service User Guide that informs prospective service users about the service, the aims and how these are met. A copy of the recent inspection report is available in the home for anyone to read. Finchley House DS0000015744.V309212.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This planned unannounced inspection took 7 hours over one day in September 2006. The views of two service users and four members of staff were sought. As both service users have communication needs their satisfaction of the service was interpreted not only through speech but the observations of body language, interaction with staff, discussions with staff and the examination of records. This process demonstrated that all were satisfied with the service and the care and support given by staff. Questionnaires were sent out to the relatives of the service users prior to the inspection. Five of the service users’ relatives returned them and all were complimentary about the service delivered at Finchley House. Some of the comments include; “I think my is well looked after.” is in all aspects excellent.” “The care taken of my “My has been at Finchley House since it opened and it is better now than it ever has been.” As part of the inspection process a tour of the building took place and the service users’ care files and a sample of the homes records were examined. What the service does well: The manager, staff and service users at this home work hard together to make this home interesting and a good place to live. Service users are supported to learn about their rights and what is expected from them. This home is kept clean, is attractively decorated and has good quality furniture. Staff support service users to choose the colours they want their bedrooms to be and the sort of furniture they want in them. This means that service users have a pleasant and comfortable place to live and their bedrooms are the way they want them to be. Some of the staff have worked at Finchley House for a long time and know the service users well. All of the staff are taught how to support and care for people with learning disabilities. Staff and service users get on well together and when visitors come they are made to feel very welcome. This makes a good feeling in the home. Finchley House DS0000015744.V309212.R01.S.doc Version 5.2 Page 6 Staff work hard to help people living in the home take part in different activities that they choose. Some of these activities include cycling on special bikes for people with disabilities, 10 pin bowling at the local bowling alley and going on holiday to different places abroad. Service users are encouraged to take an important part in running the home. Staff help them to keep their rooms tidy and the home clean. So that service users know what is going on and have a say in how the home is run documents that describe this are developed in words and pictures. Staff listen to service users and discuss with them their ideas about how the home should be run. Care plans include good information that tell staff how a person likes to be supported. Care plans are also developed in words and pictures so that service users know what is written about them. Meetings take place between service users and anyone else the service user wants to be there, to discuss life at Finchley House and to see that the service user is still happy with their life there. To describe what was discussed in the meetings service users and staff have developed a report with words and photographs. This describes the service user’s present lifestyle and at the end the service user has said what things they want to continue and what new things they want try in an easy way to understand. What has improved since the last inspection? What they could do better: Finchley House DS0000015744.V309212.R01.S.doc Version 5.2 Page 7 There should be more information written in the service users’ contracts so that service users know the full cost of their fees and how these are to be paid. When medication is received into the home the date that it was received, the amount that was received and the signature of the person who received it must be recorded on the medication record sheet. This will protect service users from possible mistakes being made. Staff must attend special training with the local council to learn about the steps to take and who to contact, if they see or hear about something happening that might hurt a service user or make them feel unhappy. The manager must contact the Fire Service to ask them to make an inspection of the home, so that they can check that the fire procedures and fire fighting equipment in place, will keep the service users and staff safe in the event of a fire. 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. Finchley House DS0000015744.V309212.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Finchley House DS0000015744.V309212.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,4,5 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Good multidisciplinary preadmission assessments are in place that demonstrates service users’ needs and aspirations and help the home to decide whether they can meet them. So that service users are aware of the terms and conditions of their residency they are issued with a Contract that informs them of the terms and conditions of their stay, however they are not informed of the full cost of their fees and how these are to be paid. This could confuse service users and their representatives. EVIDENCE: Documents were in place to prove that a variety of information from appropriate agencies, the service user and their representative is sought prior to admitting new service users to the home. Finchley House DS0000015744.V309212.R01.S.doc Version 5.2 Page 10 For one service user preadmission assessments were in place from the Care Manager and other professionals involved in their care. Information from a previous home had also been sought and during visits to that home and during the time the prospective service user visited Finchley House, staff also carried out there own assessment. The culmination of such information had enabled the home to make a judgement that they could appropriately meet the needs of the service user. Records and observations made confirmed that the needs of the service user are being addressed appropriately and that they are experiencing a good quality of life. Records demonstrate that each service user is offered a contract stating the home’s terms and conditions of their stay. In an effort to make the document accessible to service users a copy of the document is written in simple language and illustrated with pictures. However although the service user or their representative signs the document, it does not include the full cost of the fees to be paid to the home or how they are to be paid. The need to have this recorded and agreed to was discussed with the manager who agreed to address it. A separate document includes an agreement signed by a relative regarding how the service user’s mobility allowance is to be paid towards the cost of running the home’s vehicle. Finchley House DS0000015744.V309212.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Each service user has a care plan that is easy to understand considers all areas of their lives and includes risk assessments. EVIDENCE: The home is in the process of further developing the care-plan system so that they are service user led and recorded with a person centred approach. Pictures support the care plans in an attempt to make them more accessible to the service users. As this process is in the initial stages, the manager agreed that the amount of information gathered would eventually be selectively reduced to avoid duplication. Finchley House DS0000015744.V309212.R01.S.doc Version 5.2 Page 12 The guidelines in the care plans clearly identify the amount of support service users need with different tasks while at the same time promote service users as people with dignity and self direction. They also identify any risks that may be involved and how these can be reduced. Guidelines for staff to follow ensure a consistent approach. The opening of the care plan provides a photograph of the individual service user with their Life Story surrounding it. This is an excellent way of seeing service users as they are and where they are at in their lives and will be useful for the reader of the plan to see the person, their strengths and their needs, at a glance Staff and observations confirmed that service users’ independence is promoted and they are encouraged to take control over their own lives. Records confirmed this and action plans describing how personal goals are to be achieved were in place. Records also confirmed that the service user and their key worker monitor the care plans monthly and review them six monthly, when other people involved in their lives are invited to attend. Staff have supported service users to produce a record of the outcome of their review by recording the individual’s recent life events, with photographs and simple dialogue. These records clearly demonstrate what the service user has achieved, what they have been involved in, where they are at in their lives and what they want to achieve next. This is an excellent way of demonstrating the lifestyles individual service users are choosing to enjoy and what they want to do next. The staff are congratulated on this piece of work. Finchley House DS0000015744.V309212.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Service users are supported to take part in a variety of leisure and community based activities, and as a result live a valued lifestyle, while at the same time are successfully supported to maintain personal and family relationships. To also maintain a balanced and healthy lifestyle varied, wholesome food is provided by the home. EVIDENCE: Service users continue to be involved in a variety of activities based in the local community. Part of the week for some also includes attending activities at local daycentres. Finchley House DS0000015744.V309212.R01.S.doc Version 5.2 Page 14 Care plans clearly record individual service users likes and dislikes which staff stated help them when supporting service users to make choices. Care plans and care practice observed, confirmed that staff value and respect service users’ right to make choices and be part of the community. One care plan recorded “I wish to access the community as much as possible and to be given equal rights while doing so.” Records confirmed how this is achieved, some of the activities include attending a local craft session at the nearby Quaker House, going for bike rides, where bikes specially adapted for people with disabilities are available, and going 10 pin bowling. Activities are also arranged to take place in the house and include reflexology and music therapy. At the time of the inspection four service users were on holiday in Turkey and were due to return that evening. The manager explained that this is the third different holiday destination abroad service users had chosen to go to in three years. The remaining service users with the support of staff explained that going abroad had not been their choice. Service users are involved in choosing meals, and menus are based on their known preferences. A light lunch was taken with the service users and staff at the dining table where much of the discussions took place. Staff confirmed that although service users are encouraged to take meals at the dining table some chose to have breakfast in the kitchen. Finchley House DS0000015744.V309212.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Service users personal and healthcare needs are met in a flexible but consistent manner, with the aim of allowing service users to take the lead. Medication arrangements are appropriate for the needs of service users and are managed in a safe manner. EVIDENCE: Staff support service users to address their individual healthcare needs by assisting them to visit local GPs and attend hospital appointments. The outcomes of such visits are recorded in individual care files. The observation of the interaction of staff with service users demonstrates that personal support is delivered in a discreet and respectful manner. Records confirmed that specialist healthcare professionals are involved in service users lives where appropriate. Staff follow guidelines in care plans so that service users receive a consistent approach with personal support. Finchley House DS0000015744.V309212.R01.S.doc Version 5.2 Page 16 Guidelines were in place for one service user in relation to promoting continence and for another in relation to physiotherapy exercises. Staff confirmed that they work closely when visiting professionals so that they are guided in the best way to support service users to develop and progress. There are behaviour guidelines in place for one service user whose records demonstrate improvement. The manager stated that the healthcare professional involved had congratulated staff for the positive outcomes as a result of all staff following the guidelines set. Staff and records confirmed that they have received training in relation to the administration of medication. A check was carried out regarding the storage and recording of medication. All was appropriately recorded and stored, however there was one minor discrepancy that was brought to the attention of the manager. Although medication is generally appropriately recorded on receipt of one piece of medication staff had failed to record on the medication sheet, the date and quantity that was received. The administration of medication was appropriately recorded. Finchley House DS0000015744.V309212.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Although there is one allegation of abuse towards a service user currently being investigated arrangements are in place in the home to help protect service users from abuse and to seriously address complaints and concerns about the service. The home has demonstrated that they follow the correct procedures when abuse is reported. EVIDENCE: The home has a comprehensive Complaints Procedure, which is also in picture format. There have been no complaints made since the last inspection however three compliments were recorded. These include compliments from a service manager and two relatives congratulating staff on good care practices. Staff spoken to confirmed that they have received awareness training regarding abuse and adult protection, however not all staff have received training in relation to the local authority’s Protection of Vulnerable Adult (POVA) procedures and as it is these procedures that the home follows, it is important that all staff receive training in them. The manager confirmed that she is to contact the local authority’s POVA coordinator to arrange this. Finchley House DS0000015744.V309212.R01.S.doc Version 5.2 Page 18 A copy of the local authority’s adult protection procedures is available in the home for staff to take direction from. An allegation of abuse has been made by one member of staff against another in relation to inappropriate behaviour against a service user. Appropriate procedures have been followed by the home, the member of staff has been suspended and the appropriate agencies have been informed. The investigation is currently ongoing. Individual service user’s monies are kept in a locked safe, recorded appropriately in individual records and signed for by two staff when withdrawn. Receipts are kept of all transactions. Staff are provided with lockers to lock away their valuables while at work. Finchley House DS0000015744.V309212.R01.S.doc Version 5.2 Page 19 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): 24,30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Service users live in a homely safe and comfortable environment that is well maintained and provides adequate facilities that meets their individual needs, personality and preferred lifestyle. EVIDENCE: The house is well decorated and well maintained. As a result of three service users using wheelchairs for mobility and being encouraged to be independent, the maintenance of the internal walls and paintwork of the home is often challenged. However as a result of regular attention from the maintenance person such areas have been kept in good order. The home is comfortable and safe for the people who live here. Service users are supported to keep their bedrooms individually decorated with personal furnishings that promote their personalities. Finchley House DS0000015744.V309212.R01.S.doc Version 5.2 Page 20 One service user has a high/low bed that allows the service user to transfer from their wheelchair to bed independently. The manager confirmed that a new bed is on order for another service user. Access into and around the home is good and one service user demonstrated how they enjoy improving their mobility by walking around the perimeter. The outside of the home has recently been decorated and attractive potted plants surround the building. This makes the entrance to the building look attractive while at the same time promotes a positive image of the people who live here. Bathrooms are fitted with specialist bathing facilities and lifting equipment that meets the needs of the service users. Records confirmed that the specialist equipment is regularly maintained. This promotes the safety of the service users and staff. The plans to refurbish the laundry have currently been put on hold. Like other areas in the home this area reflects good cleaning routines. Staff confirmed that they have received training in relation to infection control. Finchley House DS0000015744.V309212.R01.S.doc Version 5.2 Page 21 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): 32,34,35 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. The staffing ratio meets the needs of the people using this service. Robust recruitment & selection procedures and regular training opportunities ensure that service users are appropriately supported and protected by a competent and qualified staff team. EVIDENCE: Two staff were on duty to address the needs of the two service users at home, while four staff were supporting another four service users on holiday in Turkey. This was an appropriate number of staff on duty. The manager stated that there is one staff vacancy of 21.5 hours that is currently being covered by a “bank” member of staff who the service users know. The manager confirmed that the employment of a member of staff to fill the vacancy is in hand. Staff discussed the needs of the service users with respect and understanding and were observed supporting service users discreetly and with respect. The development of good relationships was also observed. Finchley House DS0000015744.V309212.R01.S.doc Version 5.2 Page 22 Staff training profiles demonstrate individual training needs, training completed and the training to be done. Records and staff confirmed that there is good progress being made in relation to NVQ training, where over 50 of staff are now qualified. A member of staff recently recruited confirmed that they are working through an induction programme and had just completed training relating to The Principles of Care and stated, “staff have been very supportive and have helped me when I’ve been learning new things.” Of the staff files examined two were of staff recently recruited and included documents that reflect good recruitment procedures, these include fully completed application forms, two appropriate references and CRB checks. Finchley House DS0000015744.V309212.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. The manager, who is well supported by a senior member of staff and the staff team, provides good leadership and runs a service that has effective monitoring systems and is focussed on the best interests of the service users. EVIDENCE: The Registered Manager is fully qualified and well experienced. She has achieved the Registered Managers Award and NVQ 4 in Care and confirmed that she has enough time to carry out her managerial duties. Finchley House DS0000015744.V309212.R01.S.doc Version 5.2 Page 24 So that the staff team is effectively led, the manager confirmed that she regularly attends training related to good care practices and keeps up to date with changes in legislation. She stated that she is a Moving and Handling Facilitator and a Fire Trainer and has recently attended a three-day induction course to Foundation Training Analysis. A senior member of staff effectively assists the manager with the managerial role. The manager stated that individual duties are now delegated to staff giving them more responsibilities related to their interests and skills, this she feels empowers staff and makes them feel valued. She stated, “we work well as a team and this creates a consistent approach.” Staff and service users were observed responding effectively and showing respect towards their manager. Great efforts have been made to bring the quality assurance system together and to make policies and procedures accessible to service users. The policies and procedures are systematically being reviewed and updated where necessary during which time they are being developed into picture format. The manager has also produced a Business Plan that includes a Five Year Improvement Plan for the home, this also is in picture format and simple language that service users can access. Staff were aware of health and safety issues and carried out their roles accordingly. The fire log and accident book were examined and were satisfactory. As there has been no inspection carried out by the Fire Department since 2003 the manager was advised to contact them to request a visit, so that the fire service could advise on the home’s fire procedures if necessary. Finchley House DS0000015744.V309212.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 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 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 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 2 X 3 X 3 X X 3 X Finchley House DS0000015744.V309212.R01.S.doc Version 5.2 Page 26 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 YA5 Regulation 5(1)(b) Requirement The registered manager must ensure that the contract that describes the service users’ terms and conditions of their stay at the home must include the full cost of the fees to be paid and who is responsible for paying them. The registered manager must ensure that the receipt of medication is always recorded appropriately. The registered manager must ensure that all staff receive training regarding the local authority’s procedures related to the Protection of Vulnerable Adults. As the Fire Service has not inspected the home since 2003 the registered manager must contact them to request regular checks, so that she is confident that the fire procedures and equipment in use are up to date and appropriate. Timescale for action 31/10/06 2 YA20 13(2) 31/10/06 3 YA23 13(6) 31/12/06 4 YA42 23(4) 31/10/06 Finchley House DS0000015744.V309212.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2. 3. 4. Refer to Standard YA6 YA24 YA24 YA39 Good Practice Recommendations It is recommended that the plans to reduce any duplicate information in the care plans should go ahead. The plans to extend the carport should go ahead. The plans to refurbish the laundry should go ahead. It is recommended that the quality monitoring systems are brought together as one Quality Assurance System to ensure that the service is monitored and developed in relation to the views of the service users. Finchley House DS0000015744.V309212.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Finchley House DS0000015744.V309212.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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