Inspection on 25/06/07 for Park View (14)

This inspection was carried out on 25th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Park View (14) 03/10/05

Park View (14) 05/05/05

Park View (14) 15/10/04

Park View (14) 05/05/04

Park View (14) 15/01/04

Park View (14) 11/06/03

Park View (14) 09/09/02

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

CARE HOME ADULTS 18-65 Park View (14) Hetton-le-hole Houghton-le-spring Tyne And Wear DH5 9JH Lead Inspector Miss Nic Shaw Unannounced Inspection 25 &26 June 2007 9:30 th Park View (14) DS0000015718.V334750.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 Park View (14) DS0000015718.V334750.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. Park View (14) DS0000015718.V334750.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Park View (14) Address Hetton-le-hole Houghton-le-spring Tyne And Wear DH5 9JH 0191 526 8565 P/F 0191 526 8565 selfparkview@aol.com 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) S.E.L.F. Limited Mr Calvin Moore Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Park View (14) DS0000015718.V334750.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd October 2005 Brief Description of the Service: The home is registered to provide residential care for 8 adults under the age of 65 years, it does not provide nursing care. Any health needs are addressed by the use of community health services. It specifically offers services for adults with a learning disability who are ambulant and are able to manage the stairs in the building. It cannot provide accommodation for people who have a physical disability. The house is semi detached and stands in its own grounds in what could be described as being in the centre of Hetton le Hole. It is only a short walk to the local shops. The busy shopping parade at Hetton, which has a range of facilities, including a swimming pool, is within easy reach. The building is 2 storeys high and has bedrooms on both the ground and first floor. Its design and layout ensures that it blends in with the neighbouring houses and there are no features that would indicate that it provides a residential service. The adjacent house is also owned by the same company and offers a similar service. The house like the adjacent has its own entrance a separate staff team and registered manager and is run independently. There is a large enclosed rear garden and patio area and parking which is shared between the 2 homes. The weekly baseline fee per service user is £1072.00. Park View (14) DS0000015718.V334750.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 June 2007 and was an unannounced key inspection. The inspection included information which had been provided by the manager in a questionnaire. Feedback forms were also sent to each of the service users and six were completed and returned to the Commission before the inspection. Time was spent talking to the manager, staff and most of the service users. Some time was spent looking at the home, including the lounge, some of the service users bedrooms and garden. A sample of records, including staff files, were also looked at. The inspection focused on three of the service users, all of who have with very different needs. This is known as “casetracking”, and this involved looking at what it was like, from their point of view, living at 14 Parkview. This involved talking to the service users, watching the staff’s care practices with them and checking that information obtained from discussion with staff, service users and observation was accurately recorded in the care records. What the service does well: There is good information available to help service users decide if 14 Parkview is the right place for them before they move in. The manager makes sure he gets a recent copy of the social work assessment, as well as completing his own assessment, so that he knows that the staff are able to meet the needs of potential service users. Care plans and risk assessments are excellent. 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. The food is nice and there is lots for people to do. Service users said they always felt listened to and knew what to do if they wanted to make a complaint. The building is homely and well maintained. There is a lovely big private garden at the back of the home. The staff have had lots of training, for example about epilepsy, so that they can do their job well. They have also had training so that they know what to do should they see anyone being harmed. Park View (14) DS0000015718.V334750.R01.S.doc Version 5.2 Page 6 As well as making sure the views of relatives and service users and the staff are obtained there are good quality assurance systems in place. For example: the staff carry out daily checks of the building to make sure that it is safe. The manager is very approachable, warm and friendly and works really hard to make sure service users receive an excellent service. Service users said: “I am really happy here” “the staff are really nice to me” “thank you to my best friend Ashely, (the deputy manager), for being like a mam to me” “I like the food” “I like the activities” “I am happy living in 14 Parkview” What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Park View (14) DS0000015718.V334750.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Park View (14) DS0000015718.V334750.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good information is available to help prospective service users make an informed choice about where to live. Service users health and personal care needs are always assessed prior to admission in order to determine that these can be met in the home. EVIDENCE: The service has developed a comprehensive Statement of Purpose and Service User Guide, which are specific to the service user group. These tell people about the accommodation, support and specialist services offered at 14 Parkview. The Service User Guide is in a format suitable to the needs of people who use the service with the use of pictures. There is currently one vacancy in the home. Before agreeing an admission the manager is carefully considering his own assessment as well as that obtained from the care manager to ensure that the home is able to meet the prospective service users needs. Park View (14) DS0000015718.V334750.R01.S.doc Version 5.2 Page 9 Prospective service users are also invited to “test” the service through a number of visits to the home. This also helps the manager to make sure that the prospective service user is compatible with the current service users. The assessment tool used by the service clearly focuses on achieving positive outcomes for people. The content reflects the diversity of each individual. It is holistic and covers all aspects of a person’s life from family involvement, occupation and leisure as well as personal and health care needs. Park View (14) DS0000015718.V334750.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 service users care plans are excellent and give detailed information about service users as individuals, which helps to provide good quality of care. Service users are supported to take risks and make decisions. This means that they can enjoy a range of activities as part of living an independent lifestyle. EVIDENCE: Each service user has a case file. These can be easily followed with the initial assessment documents at the front followed by the care profile and goal plans. In addition to the admissions assessment a detailed skills assessment is also completed. This covers all aspects of an individual’s daily living skills from eating, nail care, hair washing, to domestic skills. From the skills assessment goal plans are developed. Each service user, with staff support, chooses three Park View (14) DS0000015718.V334750.R01.S.doc Version 5.2 Page 11 goals to work towards. Examples of goal plans include applying make-up, cleaning teeth and ironing. Each goal plan is broken down into simple achievable steps and photographs of each step are used to help people understand and follow them. This is excellent practise and shows how the manager and staff ensure that people are in control of their lives. The skills assessment document is reviewed annually and used to establish if there have been any overall improvements or deterioration in each individual’s abilities. There is an individual care profile. This provides detailed information about each person’s personal care needs and what support they need. As well as providing the reader with a social history of the service user it includes information about their social interaction, communication, behaviour, imagination, relationships, community access, physical skills, health, medication, self care skills, eating and drinking, safety of self and others, bedroom, finances, and religion. Detailed risk evaluations are also completed and these cover areas such as mobility, environment and challenging behaviour. Within the risk evaluations any risks are identified together with what action staff should take to reduce these. They also provide information about any situation where limitations may need to be imposed, for example: if a person is unable to go out independently as the risk is assessed as too great. For people who may display behaviours which challenge the service, detailed behaviour profiles have been developed. These are excellent as they include a detailed description of the behaviours, listed in order of likelihood of occurring, followed by possible triggers and known contributory factors. Within the behaviour profiles it is clearly recorded that a “person centred approach must be adopted by using “acceptance” and “empathy””. As a result of the service working positively with people there is clear evidence that certain behaviours have reduced. One social worker had commented in a review that there had been “significant improvements” in one service users behaviours since moving to 14 Parkview. Service users are supported to make decisions, not only by staff taking time to listen to their aspirations and helping them to develop goal plans, but also through regular service user meetings. Detailed records are kept of these and show that service users have been involved in discussion about household activities such as the social sessions. Park View (14) DS0000015718.V334750.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): 12,13,15&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 both inside and outside the home. Service users are assisted to maintain links with their families and to have a regular community presence. 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: In order to meet the diverse complex needs of the service users activities need to be very structured. This is achieved by the service with full service user involvement with the use of a visual timetable activity board. This is displayed in the hallway and consists of a large board hung on the wall where pictures of Park View (14) DS0000015718.V334750.R01.S.doc Version 5.2 Page 13 activities can be easily attached and removed depending upon the structure of that day. There are many activities available to service users ranging from indoor activities including cookery sessions, memory games, quizzes, art and craft reading and computer sessions to outdoor activities such drinks and meals out and shopping, which one service user commented was their favourite activity. Two service users go out independently and they both have their own mobile phones, which they take with them. Each week everyone spends a day at the “farm” where many people are learning how to horse ride. Everyone said that they enjoyed this. On the first day of the inspection, staff were engaging people in a memory game. Everyone, regardless of their level of disability, was encouraged and supported to take part in this. Staff throughout both days of the inspection continuously interacted with service users not only offering encouragement and support but also discreetly observing and intervening as necessary if a service user showed any signs of agitation. In order to meet service users religious needs a local Minister visits the home every week. Observation of staff practices showed that the culture of the service is to encourage people to be independent. For example, incentive charts have been introduced and these are used to help service users to take responsibility for their actions. Service users said that they liked these and that they really helped them. The service users each have responsibility for a household task, for example, cleaning communal areas, and service users said they agreed the domestic rota in their service user meetings. Holidays are also discussed and chosen within service user meetings. Although none of the relatives were visiting on the day of the inspection service users said that they had contact with their families and friends. Staff help the service users to write to their friends and one relative is able to have lunch in the home with their family member. The staff are excellent at providing service users with information, support and guidance to help them make decisions about intimate personal relationships and their sexual health. Menus are planned and decided based upon the service users likes and dislikes, which is discussed in the service user meetings. Mealtimes are structured and in order to meet the diverse needs of service users two sittings Park View (14) DS0000015718.V334750.R01.S.doc Version 5.2 Page 14 for lunch have been introduced. Service users take turns in helping to prepare the meals. Service users said that there was always a choice of main meal, including a healthy option, and people said that they liked the food. Park View (14) DS0000015718.V334750.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 excellent. 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 profiles provide clear guidance to staff on the service users preferences on how their personal care needs are to be met. The care profiles are all different and the content reflects the personal care needs of each service user. Personal support is consistent and staff are clearly knowledgeable of the service users personal and health care needs and how best to offer support. Park View (14) DS0000015718.V334750.R01.S.doc Version 5.2 Page 16 Two staff always support service users with their personal care. This has been introduced as a way of protecting service users but also to protect staff from potential allegations of abuse. Advice was offered to review this practise and use the risk assessment process to help decide, on an individual basis, whether it is necessary for two staff to be present when supporting people with their personal care. All service users have access to a range of healthcare professionals such as opticians, dentists and GP’s. A community nurse visits the home every three weeks and is involved with all of the service users. Should a service user require a consultation with, for example, a psychologist, this can be arranged quickly through the community or “link” nurse rather than having to go through the GP first. A monthly review of the service users needs is carried out by the keyworker in which any changes to their health care is closely monitored. The skills assessment document is an excellent tool to monitor whether or not there has been any decline in a person’s cognitive ability, which is excellent and particularly important for people with Down’s syndrome who are more at risk of developing dementia at an earlier age. Staff are trained and competent in health care matters, particularly how to respond to those service users who may become agitated. As previously mentioned detailed behaviour profiles are in place, which are excellent, and these are regularly reviewed and up-dated. Where it has been necessary for staff to use a form of physical intervention, detailed records are maintained of this as well as the completion of an accompanying incident sheet. Medication records 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 and follow the Royal Pharmaceutical guidelines. Park View (14) DS0000015718.V334750.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 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 users money needs 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. Service users said that they would talk to a member of staff if they were unhappy or wanted to make a complaint. The complaints record confirmed that there has been one complaint since the last inspection. This has been thoroughly investigated by the manager who provided the complainant with a written response to their concerns. 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. All staff working in the home are trained in safeguarding adults procedures. There have been no safeguarding adult referrals made since the last Park View (14) DS0000015718.V334750.R01.S.doc Version 5.2 Page 18 inspection. 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 profiles in the service user’s personal files. Policies, procedures and staff practices also generally ensure the financial protection of service users. All transactions made on behalf of the service users have two staff signatures and receipts are also obtained. The manager carries out regular internal audits of the service user’s personal money. However, service users take turns paying for refreshments when they out. There is no system in place for monitoring that this equitable and therefore may mean that some service users are buying other service users more expensive refreshments than they themselves had chosen on a previous outing. Park View (14) DS0000015718.V334750.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): 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 to live. EVIDENCE: The building throughout was found to be clean. Service users said in feedback forms “my house is very nice”. The building and design of the home allows for the eight service users to live together in a non-institutional environment. There are two spacious communal lounges on the ground floor and a third lounge on the first floor which has been converted into a “snoezelen” room, which is a room equipped with a range of multi-sensory equipment such as fibre optic lights where people can spend time relaxing. The lounges on the ground floor are bright, airy, comfortable places, providing service users with plenty of space and choice of where to spend their time. There is a beautiful Park View (14) DS0000015718.V334750.R01.S.doc Version 5.2 Page 20 spacious enclosed garden at the back of the home, which everyone can safely use. All rooms are single occupancy and service users are encouraged to personalise these areas. Some of the service users took pride in showing their bedrooms. Some people have their own computers, laptops, music centres, TV’s and fish tanks. Some of the service users haven’t got a key to their room as they have lost the original, but like to keep their room locked. This means that they have to ask a member of staff to lock and unlock their door for them. When asked service users said that they would prefer to have their own key again and the manager agreed to look at how people could be supported with this. Detailed policies and procedures are available in relation to infection control and the manager and staff have all had training in relation to this. Park View (14) DS0000015718.V334750.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): 32,34&35 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 good staffing levels ensure that the service users needs are readily met. The service operates a robust recruitment procedure which protects service users from being supported by unsuitable people. EVIDENCE: Staff are provided with a range of training. In addition to the NVQ level 2 qualification in care, this has included “control and restraint”, diabetes, and the Mental Capacity Act. In addition to external training courses, team meetings are used to provide internal developmental training, which is excellent. This is the responsibility of the deputy manager of both this service and the deputy manager of the adjacent home, who strive to provide training which promotes person centred care. Examples of recent internal training include epilepsy and medication Park View (14) DS0000015718.V334750.R01.S.doc Version 5.2 Page 22 refresher training. Sometimes staff are asked to answer questions about a particular topic. Feedback is given on a 1:1 confidential basis and if needed further developmental training sessions are provided to ensure that staff are fully competent in all areas of their work. Team meetings are held every two weeks and staff are paid to attend them. Games, such as general knowledge quizzes about policies and procedures, using the “weakest link” theme, are also used as team building exercises. Service users said in feedback forms “I like all the staff”, “the staff are all nice” and “the staff always help me out as much as they can”. On duty during the inspection were the manager, deputy manager a senior member of staff and a support worker. Rotas showed that good staffing levels are always maintained. There is one vacancy in the home, however, staffing levels have not been reduced. There has been a low turnover of staff. There is a good on-call system in operation, not only so staff know who to contact if they need advice but also who to contact to cover a shift at short notice. The staff recruitment process involves the prospective employee completing an application form. The manager and deputy manager or manager and a service user carry out an interview. Two satisfactory references as well as an Enhanced Criminal Records Bureau and POVA (Protection of Vulnerable Adults) check are sought prior to offering prospective employees a position within the home. All new staff are asked to voluntarily work some short shifts alongside an experienced member of staff as part of the recruitment process. They are not expected to undertake any personal care tasks or work unsupervised during this time and this helps the manager and the service users to decide whether they should be offered a job in the home. Park View (14) DS0000015718.V334750.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): 37,39&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 an excellent quality assurance system, based on the views of the service users, so that they know their rights will be respected and their views listened to. Park View (14) DS0000015718.V334750.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. He is competent and skilled to carry out this role and in addition to the completion of the NVQ level 4 qualification in care he has undertake other training, such as “control and restraint”, epilepsy and the Mental Capacity Act to make sure his knowledge and skills are kept up to date. During the inspection staff and service users were observed to relate to the manager with confidence and respect. Service users clearly regard the manager as someone who will be able to support and help them to resolve any problems they may have. The manager is highly motivated and committed to ensuring that the diverse needs of all the service users are met to a high standard. He 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. He has continually ensured that the appropriate action, such as referral to other professionals for support and advise, has been quickly made to ensure that the staff team continue to be able to meet the needs of service users. There is a comprehensive internal quality assurance system in place. This involves a monthly audit of a range of standards, completed by the “head of care” as well as a three monthly audit completed by the manager. Internal audits include checking the number of staff on duty, asking staff about the fire procedure, checking the medication and monitoring the number of accidents. The views of service users, relatives and professionals are sought through an annual questionnaire. This information is collated and analysed and used to produce an annual report. There are a range of comprehensive policies and procedures. Staff are asked to sign the policy file to show that they have read and understood them. Appropriate records are held in relation to accidents. There is a full and clearly written recording of all safety checks, for example, the daily building checklist. The fire log book confirmed that all staff receive a regular fire drill. Alarms are checked weekly and emergency lighting and fire fighting equipment monthly. The manager has also completed a detailed fire risk assessment for the building. In addition to this every Friday there is a fire awareness session for service users. Park View (14) DS0000015718.V334750.R01.S.doc Version 5.2 Page 25 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. Park View (14) DS0000015718.V334750.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 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 x 32 4 33 x 34 4 35 4 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 4 X 4 X x 3 X Park View (14) DS0000015718.V334750.R01.S.doc Version 5.2 Page 27 N0 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. Standard Regulation Requirement Timescale for action 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 YA18 Good Practice Recommendations A review of the practise of two staff helping all service users with their personal care should be carried out. This is so that service users dignity and privacy is fully promoted. A review of the current practise of service users taking turns to pay for each others refreshments should be undertaken. This is to make sure that service users are fully protected. 2. YA25 Park View (14) DS0000015718.V334750.R01.S.doc Version 5.2 Page 28 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 Park View (14) DS0000015718.V334750.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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