Inspection on 19/07/07 for Northmead House

This inspection was carried out on 19th 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 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Northmead House 22/05/06

Northmead House 20/12/05

Northmead House 18/08/05

Northmead House 23/11/04

Northmead House 25/06/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Northmead House 3 Northmead Puriton Bridgwater Somerset TA7 8DD Lead Inspector Sally Murphy Unannounced Inspection 19th July 2007 1:30 Northmead House DS0000042169.V335881.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 Northmead House DS0000042169.V335881.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. Northmead House DS0000042169.V335881.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Northmead House Address 3 Northmead Puriton Bridgwater Somerset TA7 8DD 01823 423126 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) Somerset County Council (LD Services) * Post Vacant* Care Home 10 Category(ies) of Learning disability (0), Physical disability (0) registration, with number of places Northmead House DS0000042169.V335881.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Registered for up to 10 persons in category LD who may have a concurrent physical disability. Registered for respite care placements only. Registered to continue providing care to one named service user who is now over the age of 65 years. 22 May 2006 Date of last inspection Brief Description of the Service: Northmead House is a large detached house situated in the village of Puriton. The home provides respite care for adults who have a learning disability. Appropriate adaptations have been provided within the home to meet service users needs. There is an enclosed garden at the rear of the property. Northmead House is run by Somerset County Council. Lorraine Hartley has been appointed as Manager, and is in the process of applying to become the Registered Manager for the home. The Responsible Individual for the service is Mr David Dick. Northmead House is registered with the Commission for Social Care Inspection to provide respite care for up to ten people who have a learning disability and those that also have a concurrent physical disability. Fees are £50.00 per week for service users aged 18-24 years, and £62.00 each week for service users aged over 25 years. The charges for a 24-hour period are £8.00 for service users aged 18-24 years and £10.00 for service users aged over 25 years. There are separate charges for shorter periods. Northmead House DS0000042169.V335881.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was completed over two days. The majority of National Minimum Standards for Younger Adults were inspected during the unannounced visit on 19th July 2007. The Manager and Deputy Manager were not on duty during this visit. Therefore a further announced visit was made on 25th July 2007 to access further documentation and speak with the management team. The previous inspection was unannounced, and was completed on 22nd May 2006. On 19th July 2007 there were eight service users residing at the home. During the course of the visit a number of service users and staff members were spoken with. Care practice was also observed, records examined and a tour of the premises was made. Prior to the inspection the Manager provided CSCI with information regarding the service. Information from the document has been incorporated with this report. As part of the inspection process Comment Cards (surveys) were sent to service users, and health and social care professionals involved in their care. These had not been returned at the time of this report being written. The Inspector would like to thank the service users, staff and Manager for their time and assistance during this inspection. What the service does well: Northmead House provides respite care to service users who have a range of needs and abilities. Staff spoken with during the inspection demonstrated a good knowledge of service users’ individual needs and goals. There is a relaxed and friendly atmosphere within the home. Service users are consulted with regarding the daily running of the home, and are encouraged to exercise choice. Service users are provided with the opportunity to spend time at Northmead House, before coming to stay at the home. The home offers service users opportunities to engage with peers, access appropriate leisure activities, and exercise choice. The home has a menu that provides a balanced and nutritious diet. Staff are aware of the likes and dislikes of service users. Service users stated that they were pleased with the meals provided. Where service users are considered to be at a high level of nutritional risk, food and fluid charts are completed, and the service user is weighed regularly. Northmead House DS0000042169.V335881.R01.S.doc Version 5.2 Page 6 The home is maintained to a high standard of cleanliness. Staff are experienced and provide a good standard of care. Staff are provided with regular team meetings and supervision. Staff confirmed that they are able to express their views and feel listened to. The management team provides effective leadership for the home. What has improved since the last inspection? What they could do better: The home must ensure that care records include a photograph of the service user. It is recommended that hand transcribed entries on Medication Administration Records are confirmed and signed by a second staff member, to reduce the risk of error. When definitions are used on Medication Administration Records, staff must ensure that these accurately record the reason why a medication was not required. Two satisfactory references must be received prior to a member of staff commencing employment at the home. The manager must submit an application to CSCI to become the Registered Manager for the home. The home must obtain a satisfactory electrical hardwiring certificate. Northmead House DS0000042169.V335881.R01.S.doc Version 5.2 Page 7 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. Northmead House DS0000042169.V335881.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 Northmead House DS0000042169.V335881.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 good. This judgement has been made using available evidence including a visit to this service. Service users and their families are provided with relevant information to make an informed choice regarding admission to the home. Appropriate assessments are completed to ensure that the home will be able to meet service users’ needs. Service users are provided with the opportunity to visit the home before coming to stay. Staff take appropriate actions when there is an emergency admission. Service users are provided with a written contract that provides details of the terms and conditions of their stay. EVIDENCE: The home has a Statement of Purpose and Welcome Pack that provide details of the services and facilities provided at Northmead House. Northmead House DS0000042169.V335881.R01.S.doc Version 5.2 Page 10 Somerset County Council has produced a document entitled ‘Our Promise To You’ which outlines the standards of care that service users should expect to receive. This is displayed in the hallway in Somerset Total Communication. The care plan was examined for one service user who had recently began accessing this service. The Manager had ensured that a comprehensive assessment of need was received, and that the service user had the opportunity to visit the home before coming to stay. When arranging periods of respite care, staff give consideration to the needs and dependency levels of other service users accessing the facility at the during the same period. Due to the nature of the service, the home sometimes has emergency admissions. In these circumstances staff seek to develop appropriate plans of care as they get to know the service user, and work sensitively with the service user during this period of change. Service users are provided with a written contract. This provides details of the terms and conditions, what is and is not included in the fee and their rights and responsibilities during their stay. Northmead House DS0000042169.V335881.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 home has developed an appropriate care plan for each service user. Care plans had been regularly reviewed and updated as necessary. Service users are encouraged to exercise choice and participate in all aspects of life within the home. Service users are supported in taking risks. Records relating to service users are stored securely and appropriately maintained. EVIDENCE: Care plans are maintained for each service user. Three care plans were examined in detail. Two of the care plans seen included a photograph of the service user. Care plans provided information regarding service users needs, daily routines and preferences. Staff spoken with were aware of the specific needs and goals for each service user. At present there are fifty service users accessing the service throughout the year. Individual risk assessments had Northmead House DS0000042169.V335881.R01.S.doc Version 5.2 Page 12 been completed for each service user. Those care plans seen had been regularly reviewed and updated. Service users are encouraged to exercise choice, and independence is promoted. Service users spoken with stated that they enjoyed participating in tasks within the home, and that they are consulted regarding the meals and activities provided. The home operates a Key Team system to ensure that the home continues to meet the needs of each service user accessing the service. There is a notice board in the hallway displaying who will be on duty each day. Staff have been provided with Inclusive Communication Environment training. This aims to increase opportunities for choice and promote independence. Staff will support service users in managing their finances where required. Financial records were examined for two service users. All entries had supported by receipts and two staff signatures. All records relating to service users are stored securely, and may be accessed by service users at their request. Northmead House DS0000042169.V335881.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 good. This judgement has been made using available evidence including a visit to this service. The home offers service users opportunities to engage with peers, access appropriate leisure activities, and exercise choice. Service users rights and responsibilities are respected. Service users are offered a choice of menu. Those service users spoken with stated that they enjoyed the meals provided. EVIDENCE: Service users are supported in developing and maintaining daily living skills. Staff from the home will assist service users in continuing to access social and educational resources that they would normally attend, during periods of respite care. Northmead House DS0000042169.V335881.R01.S.doc Version 5.2 Page 14 On the day of the inspection, the majority of service users were at home, and were spending time in communal areas or their rooms as they prefer. Some service users were accessing day facilities. Staff spoken with confirmed that service users access local facilities including day centres and shops. Staffing levels are varied in response to service users needs, and daily routines. Since the last inspection the range of in-house activities available has increased. Further equipment has been purchased including two pool tables, outdoors equipment, and sensory aids. As a respite service, staff have frequent contact with service users family members, when service users arrive and leave the home. Care plans provide details of service users personal and family relationships. Service users rights and responsibilities are respected. Service users are able to lock their bedroom door if they wish. One of the service users staying at the time of the inspection had chosen to do this. Some service users accessing the service have an advocate. The home has a menu that provides a balanced and nutritious diet. Staff confirmed that they are aware of the likes and dislikes of service users. Detailed plans were available in the kitchen for individual service users with specific dietary preferences and needs. On the day of the inspection, teatime was relaxed and unhurried. There were a range of foods available. Appropriate meals had been prepared for those service users requiring a soft diet. Service users spoken with during the inspection stated that they were pleased with the meals provided. Northmead House DS0000042169.V335881.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with appropriate assistance to meet their personal care needs. The home supports service users in accessing healthcare services. The home has a medication policy, and all staff are provided with medication training. The management of medication is generally good, however the home must take further action to ensure that the recording of medication follows best practice. EVIDENCE: Service users are provided with support to undertake personal care tasks as required. The level and type of assistance is specified within their care plan. Service users receive assistance from a member of the same gender wherever possible. Staff support service users in accessing healthcare services and ensure that specialist advice is sought as necessary. On the day of the inspection there were two Psychologists visiting the home to complete an assessment for one Northmead House DS0000042169.V335881.R01.S.doc Version 5.2 Page 16 service user. The District Nursing team visits regularly to administer insulin for one service user who is diabetic, and will provide further support as required. Staff had provided appropriate support to one service user during their recent hospital stay. Where service users are considered to be at a high level of nutritional risk, food and fluid charts are completed, and the service user is weighed regularly. Due to the nature of the service provided, there are a number of admissions and discharges from the home. Staff ensure that clear records are maintained of all medication entering and leaving the home. Currently medication is stored securely in each service users’ room. This home is currently planning to change the system so that medication is held centrally. Staff are provided with medication training. The Manager ensures that there are sufficient staff on each shift that have received training in the administration of rescue medication such as Midazolam and rectal Diazepam. Medication Administration Records were examined for two service users. For one service user hand transcribed entries had only been signed by one staff member. It is recommended that hand transcribed entries are confirmed and signed by a second staff member to reduce the risk of error. Within the Medication Administration Record for the second service user, it was noted that some medication had not been administered and a definition recorded. However it appeared that the same definition had been used to record both times when they were at day services, and occasions when the medication was not required. Therefore records did not accurately reflect the reason for nonadministration. These matters were discussed with the senior member of staff during the inspection. Medication management was examined for two further service users during the visit on 25th July 2007. It was found that Medication Administration Records had been appropriately maintained, and that handtranscribed entries were supported by two staff signatures. An opening or discard date had not been recorded for Sodium Valporate or sudocrem, however discard dates had been recorded for eye drops and ear drops that were in use. The Inspector will send the home information regarding opening and discard dates for liquid preparations and creams. Northmead House DS0000042169.V335881.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 home has an appropriate complaints procedure and policy relating to the Protection of Vulnerable Adults. EVIDENCE: The home has a complaints procedure, which is also available in Somerset Total Communication. Information is also provided on the notice board regarding service users rights. The home has obtained a copy of the video produced by Somerset County Council, entitled ‘I want to make a complaint’. The home has developed a complaints and compliments log. There have been a number of complaints made by service users regarding a further service user who cries out loudly at night. Staff are aware of the impact of this, and taking appropriate actions. A further complaint was made and had been acted upon appropriately by the Manager. The home has received a number of compliments from service users, their relatives and professionals involved in their care regarding the service provided by the home. The home has appropriate policies relating to the Protection of Vulnerable Adults and whistleblowing. Northmead House DS0000042169.V335881.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): 24,25,26,27,28,29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has been decorated and furnished to a good standard. Appropriate adaptations have been provided. The home has sufficient communal areas and bathrooms to meet service users’ needs. The home was found to have a high standard of cleanliness. EVIDENCE: Northmead House is a large detached property situated within the village of Puriton. Service user accommodation is provided over two floors. A passenger lift is available. Communal space comprises of a lounge, large dining room and kitchen. There is an enclosed garden at the rear of the property that is accessible to wheelchair users. Northmead House DS0000042169.V335881.R01.S.doc Version 5.2 Page 19 Service user rooms are single occupancy, and all but one have en suite facilities. Two rooms on the ground floor and one room on the first floor have overhead hoists fitted. Service users rooms have been decorated to a good standard. Service users are able to bring possessions with them into the home. There are two assisted bathrooms and one wet room at the home, and additional toilets close to communal areas. All toilets and bathrooms have appropriate locks fitted. Since the last inspection two new sofas have been purchased for the lounge, and new pictures put up. There is a large TV and DVD available. This room appears comfortable and homely. During the tour of the premises it was also noted that the chest of drawers within room 10 are broken and require replacement or repair. A member of staff was advised of this on 25 July and stated that they would remove these from the room and replace them with some that were in storage within the garage. The plasterwork near room 9 requires repair within the general redecoration program for the home. The Manager had advised that annual meetings are to be held with Property Services to agree areas for improvement within the home. The laundry and kitchen areas were clean and well organised. Appropriate hand washing facilities had been provided for staff throughout the home. The home had been maintained to a high standard of cleanliness. Northmead House DS0000042169.V335881.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): 31,32,33,34,35 & 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are experienced and provide a good standard of care. Staffing levels are appropriate to meet service users’ needs. The use of bank and agency staff must be carefully monitored. Recruitment procedures had not been operated fully for one staff member. Staff have been provided with regular opportunities to attend both mandatory training, and specialist training related to the needs of service users receiving care at the home. Staff receive appropriate support and supervision. EVIDENCE: Duty rotas are maintained. There are generally five staff on duty throughout the day, and one waking and one sleeping-in member of staff at night. However staffing levels are varied according to the number of service users receiving support and their dependency needs. Northmead House DS0000042169.V335881.R01.S.doc Version 5.2 Page 21 Two service users accessing the service require 1:1 staffing. As a result of the increased dependency levels of service users receiving respite care, staffing levels have been increased. At present 1-2 bank or agency staff are being each day and 2-3 bank or agency staff during some weekends. Due to the range of needs of those service users accessing the respite facility, the registered person should review staffing arrangements to ensure that service users receive support from staff who have a good knowledge of their individual needs and preferences. On the day of the inspection, some staff were receiving Physical Intervention training. Staff advised that this is provided on a three monthly basis. Staff confirmed that training had been provided on the protection of vulnerable adults, and autism. One staff member felt that the training on autism had been particularly useful in helping staff provide a better service for one young person who accesses the service. Staff advised that training was taking place regarding the implications of the Mental Capacity Act. Six out of the sixteen staff employed have obtained the NVQ level 2 qualification and a further five are studying towards this. Two members of staff has been employed since the last inspection. These recruitment files were examined. It was found that a POVA First check had been completed prior to them commencing employment at the home. For one staff member only one written reference was recorded. The recruitment file for the second staff member was found to contain all required documentation. The Manager stated that verbal confirmation of a satisfactory CRB disclosure is received prior to an agency or bank member of staff commencing work at the home. They plan to review this process so that a written confirmation is received. Staff spoken with confirmed that they had received appropriate support and that there are regular staff meetings and supervision. Northmead House DS0000042169.V335881.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): 37,38,39, 40, 41, 42, 43. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run. There is a relaxed and open atmosphere within the home. The Manager must submit an application to CSCI to become the Registered Manager of the home, in compliance with the Care Standards Act 2000. The Manager has generally taken appropriate actions to promote the health and safety of staff and service users. EVIDENCE: Lorraine Hartley has been appointed as the Manager at Northmead House. She is experienced in providing care to adults with a learning disability, and Northmead House DS0000042169.V335881.R01.S.doc Version 5.2 Page 23 has focused upon improving care planning and staff training within the home. Ms Hartley has not yet submitted a completed application to CSCI to become the Registered Manager for the home. This must be addressed as a matter of urgency to comply with the Care Standards Act 2000. The Deputy Manager has been in post for almost a year and brought additional management support to the home. Staff and service users spoken with stated that the Manager and Deputy Manager were approachable, and that they felt listened to. Regulation 26 visits are conducted on a monthly basis. A newsletter is sent to parents and carers. The home issues questionnaires to service users and their families on an annual basis. The Manager is in the process of developing questionnaires that are more specific to the respite service provided. The home has appropriate policies and procedures in place to safeguard vulnerable service users. All records relating to service users are stored securely in accordance with the Data Protection Act 1998. Somerset County Council provides appropriate Employers Liability insurance. Fire safety records were examined. Fire equipment is serviced and tested as required. There are notices displayed in each room in Somerset Total Communication that provide details of the actions to be taken in the event of a fire. All staff members had been provided with updates fire safety training. Equipment servicing records had been appropriately maintained. Kitchen records had been appropriately maintained. The home must obtain a satisfactory electrical hardwiring certificate. Hazardous substances had been stored securely and were not accessible to service users. Northmead House DS0000042169.V335881.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 3 3 3 3 3 2 Northmead House DS0000042169.V335881.R01.S.doc Version 5.2 Page 25 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. 2. Standard YA6 YA34 Regulation 17 (1) Sch 3 (2) 19 (4) [b] & Schedule 2 8 (1) (a) Requirement Care records must include a photograph of the service user. Timescale for action 10/09/07 Two satisfactory references must 03/08/07 be obtained prior to a member of staff commencing employment at the home. The manager must submit an application to CSCI to become the Registered Manager for the home. (Previous timescale of 21/07/06 not met). 31/08/07 3. YA37 4. YA42 13 (4) [c] The home must obtain a satisfactory electrical hardwiring certificate and forward a copy to CSCI. 10/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Northmead House DS0000042169.V335881.R01.S.doc Version 5.2 Page 26 No. 1 Refer to Standard YA20 Good Practice Recommendations It is recommended that hand transcribed entries on Medication Administration Records are confirmed and signed by a second staff member, to reduce the risk of error. When definitions are used on Medication Administration Records, staff must ensure that these accurately record the reason why a medication was not required. An opening or discard date should be recorded for liquid preparations and creams. 2. YA33 It is recommended that the registered person review the use of agency and bank staff within the respite facility. Northmead House DS0000042169.V335881.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Northmead House DS0000042169.V335881.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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