Inspection on 31/07/07 for Fossdyke

This inspection was carried out on 31st July 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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 Fossdyke 9 Fossdyke Regent Street Gateshead NE8 1HH Lead Inspector Miss Nic Shaw Key Unannounced Inspection 31 July &13th August 2007 10:30 st Fossdyke DS0000066716.V340424.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 Fossdyke DS0000066716.V340424.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. Fossdyke DS0000066716.V340424.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fossdyke Address 9 Fossdyke Regent Street Gateshead NE8 1HH 0191 4333000 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) Gateshead Council Lesley Mosey Care Home 1 Category(ies) of Learning disability (1) registration, with number of places Fossdyke DS0000066716.V340424.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection New service Brief Description of the Service: Fossdyke offers a short break service to people who have a learning disability. The building is designed staffed and managed to provide a service to one person at any one time. The service cannot provide nursing care. The home is a single story building. Accommodation comprises of a lounge, kitchen, bedroom, with en-suite toilet, and bathing facility. There is a separate toilet for visitors and staff. There is a private garden to the rear of the building, which has been paved to provide level access, and parking is available at the front of the home. The home is situated in an ordinary housing estate in the Leam Lane area of Gateshead where access to community facilities such as shops, public houses, librarys and churches can be easily reached. The fee payable by the service user is £10.98 per night. Fossdyke DS0000066716.V340424.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two days in July and August 2007. Due to the nature of the service and the complex needs of the service users the inspection was announced. On the first day of the inspection there was no-one using the service and therefore time was spent talking to the manager and staff. A random selection of care plans and other records were looked at and the inspector was shown around the home. The inspection focused on three service users, all of who have with very different needs. This is known as “case tracking”, and involves looking at what it is like, from their point of view, staying at Fossdyke. This involved arranging a second visit to the home to meet one of the service users. Time was spent watching the staff’s care practices with them and checking that information obtained from discussion with staff and observation was accurately recorded in the care records. In order to find out what relatives thought about Fossdyke a questionnaire was sent out to them. The Commission received one completed questionnaire before the end of the inspection. What the service does well: There is plenty of time for service users to meet and get to know staff before they stay at Fossdyke. This helps to make sure they have a good time during their short break there. There is lots of information available so that prospective service users and their families know that Fossdyke will be able to meet their needs. The manager makes sure she gets a recent copy of the social work assessment, as well as completing her own assessment, so that she knows that the staff will be able to meet the needs of potential service users. Care plans and risk assessments are good. These are kept up to date so staff know what they need to do to meet the personal, social and healthcare needs of the service users whilst at the same time helping them to live independently. As only one person stays at Fossdyke at any one time this means that activities are based around that person’s interests. The home has its own transport, which is very good, as this means people can enjoy day trips further away. The food is nice and lots of choices are available. Fossdyke DS0000066716.V340424.R01.S.doc Version 5.2 Page 6 The service users can have lots of contact with their families during their stay. Relatives said they knew how to complain and staff have had training so that they know what to do to stop people from being abused. The house is homely and clean. The staff have had lots of training so that they can do their job well. As well as health and safety training this has included specialist training such as “Team Teach”, (so that they know the best way of supporting people with unpredictable behaviour), and equality and diversity. There are always plenty of staff around so that people can enjoy any activity they choose when they come to stay. As well as finding out what relatives and service users think about the service there are good quality assurance systems in place to make sure that high standards of care are provided. For example: the manager completes a health and safety check every month to make sure everything is working properly. When a person comes to stay at Fossdyke the service provided is built around their individual needs and choices, which is excellent. Relatives said: “I can find no faults with Fossdyke” “Fossdyke meets all my family members needs and more”. What has improved since the last inspection? What they could do better: The manager should write to prospective service users, before they stay at Fossdyke, to let them know that the home can meet their needs. The staff should write down the names of all the medicines they have given to the service users. It would also be good practise for the manager to keep a copy of the receipts staff get when they have spent money on behalf of a service user. Staff should also keep a copy of the receipt they give to relatives when they give staff money. This will help the manager to make sure service users are fully protected. Fossdyke DS0000066716.V340424.R01.S.doc Version 5.2 Page 7 Nightstaff need more regular fire drills so they know what to do if there is a fire at night. There should be a procedure on death and dying so that staff know what to do should this ever happen. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Fossdyke DS0000066716.V340424.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 Fossdyke DS0000066716.V340424.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4&5 Quality in this outcome area is excellent. Good information is available to help prospective service users and their relatives make an informed choice about whether Fossdyke is able to meet their needs. The admissions and assessment process is excellent and ensures that the services offered by the home meet the diverse needs of the service users. EVIDENCE: There is a Statement of Purpose and a Service User Guide. These documents provide prospective service users and their relatives with clear information about the services and facilities available at Fossdyke. They clearly set out the aims and objectives of the service and are available in alternative formats such as large print and pictures to help people understand them. Referrals are made to the service through the Primary Care Trust and Social Care joint panel. Once funding has been agreed the manager obtains a full needs assessment from the care manager. She then arranges to meet the family and prospective service user in their own home in order to undertake Fossdyke DS0000066716.V340424.R01.S.doc Version 5.2 Page 10 her own assessment of the service user’s care needs. The family and service user are also invited to visit Fossdyke as part of the introduction to the service. The manager, however, does not write to the service user confirming with them that, having looked at the assessment, the home is able to meet their needs. This is a legal requirement. Staff have had plenty of time to get to know the service users before they stay at Fossdyke. This involves the keyworker visiting them in their own home and spending time with them in other environments such as their day service, school, or children’s short break service. Staff said that this really helped to give them the confidence and competence to meet the service users care needs. Everyone has been provided with a copy of the residency agreement and this document, as well as the Statement of Purpose and Service User Guide, is discussed with families as part of the admissions process. Fossdyke DS0000066716.V340424.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9&10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care needs recorded in the care plans fully reflect the service users physical, emotional and social care needs. Service users are supported to take risks and make decisions. This means that they can enjoy an excellent range of activities as part of living an independent lifestyle. Service users know that their confidences will be kept when using the service. EVIDENCE: Each service user has a case file. These can be easily followed and include care plans and detailed behaviour support plans. The key workers are responsible for developing the care plans. These clearly identify the aim of the plan, such as the support each service user needs with their personal care and Fossdyke DS0000066716.V340424.R01.S.doc Version 5.2 Page 12 their communication, and the action staff need to take to ensure that this is achieved. Care plans are regularly reviewed and kept up to date. Behaviour support plans are person centred. They include a detailed description of the person’s behaviour, any situations which may trigger the behaviour and what staff should do should such a situation arise. The parents, keyworkers and senior staff have signed the behaviour guidelines. Risk assessments are completed and are an integral part of the behaviour support plans. These identify any risks which may be encountered when service users take part in activities in the home or in the community. The service has a “can do” attitude and risks are managed positively to help service users lead fulfilled lives when at Fossdyke. They also provide information about any situation where limitations may need to be imposed, for example, if a person is unable to use the kitchen as the risk is assessed as too great. The service users who stay at Fossdyke have complex communication needs. In order to support them to make decisions for themselves the staff use a range of communication aids such as pictures, objects and Makaton. A picture board is located outside the kitchen so that service users can communicate by selecting the appropriate picture when they want a drink or something to eat. Service users are able to choose which staff they would like to support them with their personal care. Service users individual records are kept in a secure locked filing cabinet and all staff have been given training on the home’s confidentiality policy. Fossdyke DS0000066716.V340424.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. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16&17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported to take part in a wide range of activities in the local community. Service users are also assisted to maintain links with their families and this enables them to lead a full and enjoyable life. Service users are provided with a nutritious, varied diet which helps to promote their general health and well being. EVIDENCE: The excellent staffing levels means that every day the routines, activities and plans are service user centred and can be quickly changed in response to the individual’s changing needs, wishes and interests. Activities are offered to service users by staff based upon the individual’s likes and interests. On the second day of the inspection one service user was preparing for a trip out to Newburn followed by a trip to the cinema at the Alan Shearer Centre. Fossdyke DS0000066716.V340424.R01.S.doc Version 5.2 Page 14 There is an activities file which includes pictures of the many activities people have enjoyed during their stay at Fossdyke. It is also used as an aid to help service users choose what they would like to do during their stay. Activities range from going to the disco, swimming, feeding horses and walks in the countryside and along the quayside. The home has its own transport so that service users can enjoy trips further away. Some service users have a bus pass and in such situations use of community transport is encouraged. Service users maintain contact with their relatives when they stay at Fossdyke. Staff encourage parents to phone if they want to find out if their son/daughter is settling in. They can also visit if they want to and one service user’s niece did so during their family members stay. Relatives said that the staff always informed them if there was anything they needed to know about. Meals are based upon the service users likes and tastes and staff use this information to prepare the menu prior to each individual’s stay. The support each person needs with mealtimes is clearly recorded in their care plan to an excellent standard. Drinks and snacks are available at all times and appropriate communication tools are used to help people choose what they would like. Where possible service users are encouraged to prepare their own meals and snacks. Fossdyke DS0000066716.V340424.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20&21 Quality in this outcome area is good. Service users receive the support they need from staff to ensure that their personal, physical and emotional health needs are met. There are satisfactory medication policies in place, however, one aspect of the recording procedure needs to be reviewed to fully protect the service users. The policies and procedures do not inform the service users that should they become ill or die this will be handled with sensitivity and respect. EVIDENCE: The staff have worked hard to build up trusting relationships with the service users in their own home, particularly for those people who require support with their personal care. As part of the introduction to the service staff work alongside the parents in order to learn from them and ensure the service users receive personal support in a way that they prefer. This also involves finding out about their daily routines and how they communicate if they are feeling unwell. Relatives confirmed that the staff went to their home to observe how they supported the service user’s with their personal care as well as how they Fossdyke DS0000066716.V340424.R01.S.doc Version 5.2 Page 16 administered the medication and said that they “wrote everything down step by step”. Staff provide service user’s with support in relation to their intimate personal care in a sensitive, discreet manner, carrying out care tasks in the privacy of the person’s bedroom. Staff are very aware of healthcare triggers, particularly in relation to epilepsy, and knew what to do to meet the service users needs. There is a medication policy available to staff and this includes ensuring that relatives bring the service user’s medication to Fossdyke within the original pharmaceutical container. This is important as it minimises the risk of medication administration errors occurring. The manager has assessed all staff as competent to administer medication. In addition to this staff have either completed or are in the process of completing certified medication training. The manager is liaising with a local pharmacist in order to review the current recording format to ensure that this is appropriate for a short break service. In the majority of cases medication records examined confirmed that medication is administered to the service users appropriately. However, when medication is dispensed in a sealed cassette, and brought into the home by the relatives in this way, staff do not list the medication they have administered to the service user. Instead they record “administered as per instruction on cassette”. Subsequent advice from the Commission’s pharmacist confirms that this is not good practise and staff should maintain a full record of the medication they have administered. There is no information available to advise staff of what to do in the event of the death of a service user whilst staying at Fossdyke. Fossdyke DS0000066716.V340424.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22&23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The views of service users and their families are taken seriously and appropriate action is taken to resolve concerns and complaints. Appropriate policies and procedures are in place, supported by staff training, which offer service users protection from abuse and neglect. However, the home’s practices regarding service user’s money need to be reviewed to fully protect people. EVIDENCE: There is a complaints procedure in place which is available in picture format to help people understand it. Staff have had training so that they know what to do should a service user or their family complain to them. Relatives said that they have not needed to raise any concerns about their family members care, but if they did, they felt confident that any problems would be dealt with immediately. There have been no complaints since the home opened. Instead there are a number of cards from service users and their relatives expressing their gratitude for the service provided. The home has its own policy and procedure documents relating to abuse which are available to staff to guide them if they have any concerns in this area. Fossdyke DS0000066716.V340424.R01.S.doc Version 5.2 Page 18 All staff working in the home are trained in safeguarding adults. There have been no safeguarding adults referrals made since the home opened. This is as a result of lack of incidents rather than a lack of understanding about what incidents should be reported. Individual staff are also highly trained to respond appropriately to physical and verbal aggression and fully understand the use of physical intervention is only to be used as a last resort. This is re-enforced in the behaviour support plans in the service user’s personal case file. The manager confirmed that receipts are obtained for all purchases made on behalf of the service users, however, these are not kept by the service as they are given to the family when the service user returns home. Although receipts are issued to families when they give money to staff on behalf of the service users, duplicate receipts are not kept. Therefore, it is not possible to complete a full audit of financial transactions made to ensure that service users are fully protected. Fossdyke DS0000066716.V340424.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29&30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment is homely, comfortable and clean providing the service users with a safe place when they come to stay. EVIDENCE: The building throughout was found to be clean, tidy and smelt fresh. Relatives said in feedback forms they had been consulted about most things in the building from the colour of the bedding and types of furniture to buy. When service users stay at Fossdyke they are encouraged to bring with them their personal possessions to make the environment homely and familiar to them. There is one lounge, a small kitchen and one bedroom with en-suite shower and bath. There is a paved private area to the rear of the home. Although facilities are limited they meet the needs of those people who use the service. Fossdyke DS0000066716.V340424.R01.S.doc Version 5.2 Page 20 The en-suite bathroom has been provided with an appropriate bath aid suitable to the needs of the current service users. There are pictures on doors to help service users find their way around when they come to stay. Detailed policies and procedures are available in relation to infection control and the manager and staff have all had training in relation to this. Fossdyke DS0000066716.V340424.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,45,35&36 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users benefit from skilled, experienced staff and the excellent staffing levels ensure that the service users needs are readily met. Service users are supported and protected by the home’s recruitment practices. EVIDENCE: There are always two staff on duty during the day and two waking nightstaff. As the service is registered for only one service user at any one time these staffing levels are excellent. Staff are provided with a range of training. In addition to the NVQ level 2 and NVQ level 3 qualification in care, this has included “Team Teach”, equality and diversity, customer care, dealing with complaints and a one day training event in autism. Fossdyke DS0000066716.V340424.R01.S.doc Version 5.2 Page 22 Some of the staff were recruited in September 2006 and as the service did not open until February 2007 this enabled them to complete a thorough induction programme. Staff said that as the service users have complex needs, some of whom unpredictable behaviour, their induction involved working alongside experienced staff until they were assessed as competent and confident to work unsupervised. Probationary reports are completed at weeks 7,13 and 20. Relatives said “they (the staff) score 10/10” for meeting the service users care needs. They also said that they “strongly believed” that if their family member wasn’t being cared for properly then their anxiety and challenging behaviour “would soar”. Staff recruitment records are kept centrally so were not seen. This information is available for inspection at the Gateshead Civic Centre. However, the manager assured the inspector that the personnel staff make sure that CRB checks are completed, references obtained and full employment histories taken. Staff spoken to confirmed this. As part of the selection process an essential component of the job specification is that prospective employees have had previous experience of autism and challenging behaviour. One relative was involved in the recruitment and selection of staff. Staff said they have regular supervisions which they found very useful as this enabled them to have their say. They also said that they had been provided with a copy of the General Social Care Council code of practise. Fossdyke DS0000066716.V340424.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,& 42. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Overall management systems are effective and ensure that the health, safety and welfare of the service users is promoted. The home operates a good quality assurance system, based on the views of the service users and their relatives, so that they know their rights will be respected and their views listened to. Fossdyke DS0000066716.V340424.R01.S.doc Version 5.2 Page 24 EVIDENCE: The manger has considerable experience in a variety of care roles as well as a number of years experience in management. She is competent and skilled to carry out this role and in addition to the completion of the NVQ level 4 qualification in management she is a Registered Nurse. In order to up-date her knowledge and skills she has undertaken other training, such as “Team Teach” alongside the staff team. During the inspection staff were observed to relate to the manager with confidence and respect. Staff said that they really felt listened to and felt able to express their view and opinions with confidence. The manager is highly motivated and committed to ensuring that the diverse needs of all the service users are met to a high standard. She communicates a clear sense of direction, which reflects best practise, and this was clearly evidenced through the high standard of record keeping as well as observation of staff practices during the inspection. There is a comprehensive internal quality assurance system in place. This involves a monthly audit of a range of standards, completed by the home’s line manager. A report is completed following this audit with any issues requiring attention identified within an action plan. In addition to this the manager completes a monthly audit which includes reviewing the quality of the service user records, general documents, staff records and condition of the home. The views of service users are sought by asking them to complete a questionnaire at the end of each stay. This is provided in picture format and plain English so that it is easy for people to understand. In a recent questionnaire completed a service user had said “ the staff are really nice and give me all of the support I need”. There are a range of comprehensive policies and procedures. Appropriate records are held in relation to accidents. There is a comprehensive health and safety policy and the manager completes a quarterly health and safety inspection. All staff have received training in relation to health and safety issues such as food hygiene, manual handling and first aid. During the inspection there were no health and safety risks noted. The fire log book confirmed that all staff receive a regular fire drill, however, nightstaff need to receive this more regularly, every three months, to comply Fossdyke DS0000066716.V340424.R01.S.doc Version 5.2 Page 25 with the recommendations of the Fire Authority. assessment has been completed for the building. A detailed fire risk Fossdyke DS0000066716.V340424.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 4 3 2 4 4 5 3 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 4 33 4 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 4 3 LIFESTYLES Standard No Score 11 3 12 3 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 2 2 4 4 3 3 3 2 x Fossdyke DS0000066716.V340424.R01.S.doc Version 5.2 Page 27 New service 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 YA3 Regulation 5(1) ( c ) Requirement Timescale for action 31/10/07 2. YA20 13(2) 3. YA42 23 (4) (d) The manager must write to prospective service users confirming to them that having regard to their assessment the home is able to meet their needs. This so that service users know that Fossdyke is the right place for them to stay. A full record must be maintained 31/08/07 of all medication administered to service users. This is to ensure that service users are fully protected. Nightstaff must receive a fire 31/08/07 instruction every three months. This is to ensure they know what to do in the event of a fire during the night. 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. Fossdyke Refer to Standard YA21 Good Practice Recommendations Policies and procedures should be developed to advise DS0000066716.V340424.R01.S.doc Version 5.2 Page 28 2. YA23 staff of the action they should take should a service user become ill or die during their stay at Fossdyke. Receipts should be maintained for all purchases made on behalf of service users. A duplicate receipt book should be used so that a copy of all reciepts issued is maintained. This is to ensure that service users are fully protected from financial abuse. Fossdyke DS0000066716.V340424.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South Shields Area Office 4th Floor St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Fossdyke DS0000066716.V340424.R01.S.doc Version 5.2 Page 30 - 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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