Inspection on 07/03/07 for Kirby Close (10)

This inspection was carried out on 7th March 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kirby Close (10) 15/12/08

Kirby Close (10) 17/01/06

Kirby Close (10) 20/09/05

Kirby Close (10) 15/03/05

Kirby Close (10) 05/10/04

Similar services:

Park View (15)

Craigmore House

1 Lanark Close

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Kirby Close (10) South Shields Tyne And Wear NE34 9QF Lead Inspector Miss Nic Shaw Key Unannounced Inspection 7 & 20th March 2007 1:00pm th Kirby Close (10) DS0000000263.V330098.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 Kirby Close (10) DS0000000263.V330098.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. Kirby Close (10) DS0000000263.V330098.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kirby Close (10) Address South Shields Tyne And Wear NE34 9QF 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 454 5527 F/P www.unitedresponse.org.uk United Response Gillian Dickinson Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Kirby Close (10) DS0000000263.V330098.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th January 2006 Brief Description of the Service: Kirby Close provides ordinary housing for two people who have a learning disability. The service cannot provide nursing care. The home is a semidetached house situated in a residential area. There is a lounge, kitchen, three bedrooms, (one of which is a sleep-in room/office), and a bathroom/toilet located on the first floor. There is a garden to the rear of the home and off road parking facilities are available to the front of the house. The home is situated in South Shields within close proximity to a range of community facilities such as shops, public houses and places of worship. There are bus stops nearby which link with the main regional centres. The home also has its own transport. The weekly fees payable by service users are £62.33 Kirby Close (10) DS0000000263.V330098.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 one two days in March 2007 and was an unannounced key inspection. The inspection included information which had been provided by the manager in a questionnaire. Due to the complex needs of the service users comments cards had not been sent to them to complete, however, questionnaires were sent to each of their relatives. Both relatives had completed and returned a questionnaire to the Commission before the inspection. Time was spent talking to the manager and staff and the service users were present for part of the inspection. Some time was spent looking at the home and one service user showed their bedroom. A sample of staff records were also looked at. The inspection focused on both service users who have with very different needs. This is known as “case tracking”, and this involved looking at what it was like, from their point of view, living at Kirby Close. As the service users are not able to use speech to express their views this involved 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. What the service does well: Admissions to the home would only take place if the manager was certain the staff have the skills and ability to meet the needs of prospective service users. The people living at Kirby Close have complex needs and in order to involve them more in making choices and decisions the staff have made sure there is information in their care plans about how they communicate. Staff are also taking photographs of lots of things that the service users do to help with communication. Care plans are excellent and as well as providing information on the service users personal care needs they show how the service users are supported to take part in everything that’s going on in the home. If a service user is unwell the staff make sure they get to see their GP quickly and the staff always arrange for service users to attend other health care appointments regularly. The food is nice and lots of choices are available. The service users have lots of contact with their families and friends and relatives said that they were kept fully informed of everything going on. Kirby Close (10) DS0000000263.V330098.R01.S.doc Version 5.2 Page 6 The home is safe and clean with a nice garden. 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. Staff training is good and the recruitment procedures make sure that only suitable people are employed to work in the home. As well as making sure the views of relatives, service users and the staff are obtained there are good internal quality assurance systems in place. For example: the staff carry out regular checks of bathwater temperatures to make sure these are not too hot. The manager is very good at her job and works hard to improve things for the service users. What has improved since the last inspection? The manager has made sure that the service users relatives have read and signed the contract so that know what the terms and conditions of residency are. Risk management plans have been up-dated. These are special plans that are put in place whenever a person takes part in an activity, which might involve an element of risk, to make sure that they get the support they need to remain safe. Medication procedures are much safer. The kitchen has been re-decorated and the lounge is more homely with cushions, lamps and ornaments. All of the staff now have an NVQ level 2 qualification in care. The manager is now registered with the Commission for Social Care Inspection (which is a legal requirement). The fire risk assessment has been finished and the manager has also completed a risk assessment for the stairs to make sure that people with mobility needs are not at risk when using them. The manager has looked at whether it is still necessary to only have a small portable television in the lounge and has decided to buy a bigger one, which would be more appropriate for this area. Kirby Close (10) DS0000000263.V330098.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Kirby Close (10) DS0000000263.V330098.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 Kirby Close (10) DS0000000263.V330098.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): 2&5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are always assessed prior to admission in order to determine that their needs can be met in the home. Each service user has an individual contract so that they know the terms and conditions of residency within the home. EVIDENCE: Although there have been no new admissions to the service since the home first opened some years ago, there are clear admission policy and procedures in place. These include the manager obtaining an up-to-date care management assessment, so that she can determine whether the service will be able to meet the prospective service users needs. A copy of the service user agreement or contract is kept in a file in each service users bedrooms. Their relatives, as advocates on behalf of the service users, have signed this document to show they have read, understood and agreed to the terms and conditions of residency. Kirby Close (10) DS0000000263.V330098.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7&9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The plans of care for individual service users continue to improve and give excellent information about service users as individuals, which helps to provide a good quality of care. Service users are able to take risks and the staff continue to develop ways of communicating with the service users in order to help them make choices in their daily lives. This enables the service users to lead independent lifestyles. EVIDENCE: The key principles of the home for delivering a quality service are based on the belief that service users should be given as much control as possible over the activities of daily living. Within United Response this is called “active support” and the care plans contain detailed information of how each service user is supported by staff to achieve this. Examples of “active support” plans include Kirby Close (10) DS0000000263.V330098.R01.S.doc Version 5.2 Page 11 involvement in checking the water temperature as well as the support each service user needs to make a drink, prepare a meal and have a bath. The detail of information within the care plans is excellent and provides step by step guidance to staff on the action they need to take not only to make sure that the service user’s personal care needs are addressed but also to ensure that the service users are involved in everything going on within the home. A record of daily events is maintained and the quality of information recorded was generally very good. This is because the manager has closely monitored what staff have been recording and offered guidance and support on the quality expected through keyworker and team meetings. Behaviour management plans have also been developed and these provide detailed information on the type of behaviour each service user may exhibit. They include guidance to staff on what the person may be communicating together with the action staff should take to appropriately support the service user at such times. Information on the service users method of communication is included in the care plan. A member of staff is currently taking photographs of the activities each service user is involved with. This information will be used as a communication aid to further enable staff to support the service user’s to make decisions and choices As demonstrated through the “active support” plans service users are encouraged to be independent in all areas of their daily life, such as personal care tasks and taking part in activities inside and outside the home. All of these can involve taking a degree of risk. The manager assesses any hazards that may be involved in carrying out certain tasks, as well as identifying any benefits and pitfalls. Information about risks are recorded in the format of a risk assessment. This allows staff to give the correct amount of support to the person as well as reducing any further chances of hazard. Examples of risk assessments in place include travelling in the home’s vehicle and attending medical appointments. An advocate has recently become involved with one service user in order to support them with the possible future move to alternative accommodation. Kirby Close (10) DS0000000263.V330098.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. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,15,16&17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users have appropriate personal and family relationships and opportunities for personal development are excellent. They are also supported to take part in a wide range of activities both inside and outside the home and have a regular community presence. This will assist 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. Kirby Close (10) DS0000000263.V330098.R01.S.doc Version 5.2 Page 13 EVIDENCE: Each service user has very different preferences in the area of activities. In order to make sure they are supported to take part in activities that they enjoy the manager and staff have considered each of their likes and interests when planning the routines of daily living and arranging activities. Activities, which regularly take place, include shopping trips and drives out in the car. Plans are in place for one service user to attend a local disco. During the week both service users attend a day service, which is also run by United Response, where lots of opportunities are provided for them to take part in activities in the community. For one service user this means that they can go swimming and enjoy day trips to places of interest. The manager has a budget so that each service user can enjoy an annual holiday. Last year one person went to Portugal and this year plans are in place for one service user to go to the Lake District. As well as leisure activities the staff constantly interact with the service users involving them in all areas of daily living in the home. The service users are encouraged to see the home as their own and are always supported by staff to answer their front door and attend to visitors and guests. The staff constantly look at ways of how the service users can be involved in activities in the home. For example: in order to enable one service user to be more involved in the kitchen a special table has been purchased so that they can take part in food preparation. There are many more opportunities for the service users to maintain and develop independent living skills and, as previously mentioned, these were all clearly recorded in the “active support” plans. Service users maintain contact with their relatives and friends. A friend was visiting one service user during the inspection and relatives are able to visit at any time. Feedback received from relatives in the questionnaire confirmed that they were always made to feel welcome in the home and that they are kept informed of important matters affecting their family member. Meals are based upon the service users likes and service users are encouraged to shop for their own food and prepare their own meals. Healthy eating is encouraged and the menu is reviewed every two months. There was lots of fresh fruit available and service users were able to help themselves to drinks and snacks throughout the day. In order to further help the service users to make choices in this area one member of staff is taking photographs of a wide range of meals the aim being to develop a picture menu. Kirby Close (10) DS0000000263.V330098.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. 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 using available evidence including a visit to this service. Service users receive the support they need from staff to ensure that their personal, physical and emotional health needs are met. The service users are protected by the homes medication policies, procedures and practises. EVIDENCE: The care plans provide detailed guidance to staff on the service users preferences on how their personal care needs are to be met. The areas covered within the care plans include bathing, dressing and cleaning teeth. The care plans are all different and the content reflects the personal care needs of each service user. Kirby Close (10) DS0000000263.V330098.R01.S.doc Version 5.2 Page 15 Care plans examined confirmed that the service users have regular access to their GP and other medical professionals such as the community nurse and consultant psychiatrist. Regular health care checks take place including dental and eye checks. Medication records examined confirmed that medication is administered to service users appropriately. Systems are in place for ordering and the safe disposal of medication. An audit of the medication held in the home was checked and correct and corresponded to the medication administration records, which are held on one file and contain good detailed information. Medicines are stored safely and securely. When ordering the medication from the GP, however, the staff do not see the prescription, which is good practise, to make sure that the correct items have been ordered before they are dispensed by the pharmacist. Kirby Close (10) DS0000000263.V330098.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. 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. Whilst service users communication skills are very limited, arrangements are in place through the complaints process to promote their safety and offer protection. Although staff training ensures that service users are protected from abuse and neglect, policies and procedures do not fully safeguard the service users. EVIDENCE: There is a complaints procedure available to the service users in plain language with large print and pictures. Due to the communication needs of the people living at Kirby Close they would not be able to use this procedure to make a formal complaint. However, it was evident that staff were well aware of the service users method of communication and how they would show whether they were unhappy or dissatisfied. This information is included in the behaviour management plans so that staff know what to do should a service user become agitated. There have been no complaints made by relatives or other professionals involved in the care of the service users since the last inspection. Relatives said in the questionnaires received that they knew how to make a complaint but had never felt it necessary to do so. Kirby Close (10) DS0000000263.V330098.R01.S.doc Version 5.2 Page 17 Staff have had training in relation to the protection of vulnerable adults. There is written information available to staff, called “prevention of abuse” advising them of their duty of care to report bad practise. However, a copy of South Tyneside’s safeguarding adults policy was not available to advise staff of key people they must contact should they witness or suspect abuse. Policies, procedures and staff practices ensure the financial protection of service users. Records showed that for all transactions made on behalf of the service users, staff signatures as well as receipts are obtained. Regular internal and external audits of the service user’s personal money are carried out. Kirby Close (10) DS0000000263.V330098.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24&30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Kirby Close provides service users with a safe place to live and improvements have been made to the environment to make this more homely and comfortable. EVIDENCE: The building throughout was found to be clean with no unpleasant odours. There is a communal lounge/dining area. This area has been enhanced with the use of ornaments, cushions, blinds, curtains and lamps. Overall the building was well maintained, and the kitchen has recently been re-decorated. Kirby Close (10) DS0000000263.V330098.R01.S.doc Version 5.2 Page 19 In the past a recommendation had been made by a psychologist working with one service user to only have a small television in the lounge so that this could be easily moved. This recommendation has been reviewed by the manager who confirmed that this no longer necessary and is soon to purchase a larger size television, which would be more suitable for this area. Each service user has their own bedroom and these areas have been well personalised reflecting the service users likes and tastes. The staff help and support the service users to keep their bedrooms clean and guidance in relation to this is recorded in the bedroom management plans. Detailed policies and procedures are available in relation to infection control and discussion with the manager confirmed that all staff have had training in relation to this as part of their induction. Protective gloves and aprons are available for staff to use. Kirby Close (10) DS0000000263.V330098.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. 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 using available evidence including a visit to this service. Service users benefit from skilled, experienced staff and staffing levels ensure that the service users needs are readily met. Staff recruitment policy and practises fully protect the service users. EVIDENCE: There were two staff on duty and rotas showed that there is always a member of staff who sleeps in the building during the night. This is the minimum staffing level for the home which is appropriate to meeting the needs of the two service users. Kirby Close (10) DS0000000263.V330098.R01.S.doc Version 5.2 Page 21 All of the staff have completed the NVQ level 2 qualification in care. In addition to this staff are provided with a range of other training, including “person centred planning”, “autism”, “communication” and “equality and diversity”. Staff said that they had been provided with induction training and that the training provided by the organisation was good. There are no staff vacancies and staff turnover is very low, which is important in terms of promoting continuity of care. Staff recruitment records confirmed that two written references as well as an Enhanced Criminal Records Bureau check and a full employment history are taken before new employees can work in the home. An interview is also carried out as part of the assessment process. Kirby Close (10) DS0000000263.V330098.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. 37,39&42 Overall management systems are excellent and ensure that the health, safety and welfare of the service users is promoted. The home operates an excellent quality assurance system, based on the views of the service users and their representatives, so that they know their rights will be respected and their views listened to. However, there needs to be more unannounced visits, by someone other than the manager, to check on standards and therefore fully safeguard the service users. EVIDENCE: The manager has the required qualifications and experience and is highly competent to run the home and meet its stated aims and objectives. Kirby Close (10) DS0000000263.V330098.R01.S.doc Version 5.2 Page 23 She has recently completed the Registered Managers Award and it was evident how the knowledge she has gained from this training has been put into practise with the current review of the induction programme and how service users can be involved in this process. The manager is person centred in her approach and is constantly striving to improve the service. An example of this is the use of video to analyse and improve staff practises. Records and discussion with the manager confirmed that the she also uses supervision systems, as well as keyworker and team meetings, to make sure staff constantly reflect upon their practice and support the service users to reach their full potential. Effective relationships have developed between service users, staff and the manager. Service users and staff were observed interacting with the manager with confidence and respect. Staff said “ she’s lovely” and “very approachable”. Although the manager is only based in the home for 15 hours per week, these hours are flexible and if necessary she is able to work additional hours. There are also stringent on call procedures in place. The remainder of her time is spent managing the day service where both service users attend and therefore contact with them is maintained throughout the week. United Response have a range of comprehensive policies and procedures which are continually reviewed and amended. Key policies are also available in different formats to assist those people with communication needs. There is a policy on equality and diversity which provides staff with detailed information and guidance in this area. The organisation has an excellent quality assurance system in place called “getting it right”. This includes a bi-monthly audit completed by the service manager in which a selection of core standards are reviewed. However, under the requirements of regulation 26 of the Care Homes Regulations 2001, the frequency of this audit must be monthly. The service manager also carries out a more detailed audit quarterly. This information is then analysed by the quality assurance representative within the organisation who compiles an annual report. However, some of this information was not readily to hand as the documents are completed electronically, copies of which had not been saved. Kirby Close (10) DS0000000263.V330098.R01.S.doc Version 5.2 Page 24 Due to the complex needs of the service users it would not be appropriate to send them a satisfaction questionnaire to complete, however, the views of relatives, as advovates on their behalf, are sought in this way. Staff are also asked to complete annual satisfaction questionnaires. Appropriate records are held in relation to accidents and there have been no preventable accidents since the last inspection. The fire logbook examined confirmed that fire drills are regularly carried out. The manager has also carried out a detailed fire risk assessment for the building. Staff carry out regular health and safety checks, including checks of hot water temperatures, and records are maintained of this. The manager has recently completed health and safety training, as part of her management development programme, and as a result of this is currently reviewing the service’s health and safety risk assessments. She has also completed a risk assessment for the use of the internal stairs to ensure that any hazards associated with service users using these are identified and reduced. Records showed that staff have completed training in relation to moving and handling, first aid and food hygiene. Kirby Close (10) DS0000000263.V330098.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 X 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 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 4 3 X 3 X LIFESTYLES Standard No Score 11 4 12 3 13 3 14 3 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 4 X 2 X X 3 x Kirby Close (10) DS0000000263.V330098.R01.S.doc Version 5.2 Page 26 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA23 Regulation 13(6) Requirement The manager must obtain a copy of the local authorities safeguarding adults policy and procedure. The registered provider must arrange a monthly unannounced visit to the home in accordance with regulation 26. (Timescale not met 31/10/05 & 31/01/06). Timescale for action 31/05/07 2. YA39 26 31/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA20 Good Practice Recommendations The prescription from the GP should be seen by staff in order to ensure the correct medication is ordered. Kirby Close (10) DS0000000263.V330098.R01.S.doc Version 5.2 Page 27 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 Kirby Close (10) DS0000000263.V330098.R01.S.doc Version 5.2 Page 28 - 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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