Inspection on 19/11/06 for Prudhoe House

This inspection was carried out on 19th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Prudhoe House 05/06/08

Prudhoe House 24/06/07

Prudhoe House 02/02/06

Prudhoe House 08/09/05

Prudhoe House 26/11/04

Prudhoe House 22/07/04

Prudhoe House 09/03/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Prudhoe House South Road Prudhoe Northumberland NE42 5LB Lead Inspector Dennis Bradley Key Unannounced Inspection 19 November & 4th December 2006 14.00p th DS0000000648.V302831.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 DS0000000648.V302831.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. DS0000000648.V302831.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Prudhoe House Address South Road Prudhoe Northumberland NE42 5LB 01661 830786 01661 830786 prudhoe@prudhoehouse.wanadoo.co.uk 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) Northumberland, Tyne & Wear NHS Trust Ms Judith Blackburn Care Home 6 Category(ies) of Learning disability (6) registration, with number of places DS0000000648.V302831.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd February 2006 Brief Description of the Service: Prudhoe house is a registered care home for six people who have learning disabilities, situated within the community of Prudhoe. The aim of the service is to support the clients to enable them to take an active part in the community and actively choose their own lifestyle. The home is an attractive listed building and blends in with the local community; it is not recognisable as a care home. Copies of the Home’s Statement of Purpose and this Commission’s inspection reports were available in the Home. The current scale of charges was between £62.35 and £94.45 per week. DS0000000648.V302831.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit to Prudhoe House was unannounced and started at 14:00pm. The inspection involved two visits to the Home. The inspector met all six of the residents and spoke to a number of staff, including the Manager and a Deputy Manager. Questionnaires were also sent to the each resident and their relatives as well as to some of the professionals who have contact with the Home. All of the residents completed the questionnaire with the support of staff. A response was received from one relative and two social workers. The Manager had also completed a pre-inspection questionnaire. During the visits to Prudhoe House the inspector looked around the house and examined a sample of records. The Commission had not been notified of any incidents concerning the Home since the last inspection. The Commission had not received any complaints or allegations about the Home. What the service does well: These are some of the things the service does well: A relative of one person living at Prudhoe House confirmed that they were: made welcome when they visited; kept informed of important matters affecting their relative and, satisfied with the overall care provided by the Home. The social workers for two residents also said they were satisfied with the overall care provided to the people who live in the Home. One social worker said: “Prudhoe House staff have always maintained a good standard of care in my opinion”. The needs and wishes of each resident had been properly assessed before they moved into the Home. This meant that staff knew about the needs of each person and what care and support they required. Suitable plans of care and risk assessments had been done for each resident. These provided staff with appropriate information about each person’s support needs and how to minimise identified risks. The arrangements for supporting residents to make decisions about their daily lives and preferences were satisfactory. Each person was supported to take appropriate risks as part of the Home’s plans to promote as much independence as possible. Suitable arrangements were in place for residents to take part in appropriate activities in line with their needs and preferences. People took part in a range of activities. DS0000000648.V302831.R01.S.doc Version 5.2 Page 6 The residents and staff had good links within the local community and the arrangements for supporting residents to maintain contact with their friends and family were satisfactory. The relationships between staff and residents were good and personal support was provided in such a way as to promote and protect residents’ privacy and dignity. The meals provided in the home were satisfactory and provided residents with a varied diet. Suitable plans of support were in place and staff had a good understanding of each resident’s support needs. The arrangements for monitoring and meeting the health care needs of residents were satisfactory. This meant that people received the health care and support they needed. The arrangements for the administration and recording of medication were also satisfactory and protected the residents. Suitable systems were in place for handling complaints and for protecting residents from abuse. This meant that the views of residents and their relatives or representatives were listened to and acted upon and residents were protected from abuse and neglect. The arrangements for keeping the Home clean and tidy were satisfactory. The standard of the accommodation, décor and furniture and fittings was in general adequate and provided residents with a comfortable place to live. There was a competent team of staff who had access to a range of training opportunities. This meant that people were being cared for by staff who had had relevant training in meeting their care needs. The Manager was suitably qualified and she had the knowledge and experience needed to care for people who have learning disabilities and to manage a care home. What has improved since the last inspection? These are some of the things that have improved: New hoisting equipment has been installed so that the moving and handling needs of one person can be better and more safely met. Staffing levels on Sundays have been increased so that people could be supported to take part in more activities and outings. DS0000000648.V302831.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. DS0000000648.V302831.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 DS0000000648.V302831.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. The needs and wishes of each resident had been properly assessed before they moved into the Home. This meant that staff knew about the needs of each person and what care and support they required. EVIDENCE: The people who live at Prudhoe House have lived there for several years. Each person had been assessed by a range of professionals involved in their care. Where necessary, for example as a result of the changing needs of the residents, reassessments had been carried out and care and support had been reviewed. Both the social workers who completed a questionnaire said that staff demonstrated “…a clear understanding of the care needs of the residents”. DS0000000648.V302831.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Suitable plans of care and risk assessments had been done for each resident. These provided staff with appropriate information about each person’s support needs and how to minimise identified risks. The arrangements for supporting residents to make decisions about their daily lives and preferences were satisfactory. Each person was supported to take appropriate risks as part of the Home’s plans to promote as much independence as possible. EVIDENCE: The plans of care for each resident described their needs and preferences and said what staff needed to do to care for and support each person. The plans included a range of risk assessments and these detailed the steps to be taken by staff to minimise the risks that had been identified. There were arrangements in place to regularly review and where necessary update each person’s plans of care and assessments. But the moving and handling plan for one person had not been reviewed since July 2004 and their ‘Risk Management Assessment’ had not been reviewed since February 2002. The ‘Risk Assessment for Falls’ for another resident had not been reviewed or updated DS0000000648.V302831.R01.S.doc Version 5.2 Page 11 since December 2004. Records indicated that this person was falling more frequently. Records indicated the involvement of relevant professionals and agencies such as GPs, opticians and dentists. Each resident had a key member of staff who oversaw their plans of care. The plans were centred on each person’s needs and preferences. Staff supported and encouraged residents to make decisions about their daily lives and routines, such as what time they went to bed and what they wanted to eat or drink. Residents were also involved in choosing outings and activities as well as the décor of their bedrooms and the communal rooms. None of the residents were able to leave the Home without the support and supervision of staff. This was recorded in their care plan. Staff recognised that taking reasonable risks is an essential part of people’s lives and took steps to support each person to be independent while keeping them safe. DS0000000648.V302831.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17. Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Suitable arrangements were in place for residents to take part in appropriate activities in line with their needs and preferences. The residents and staff had good links within the local community and the arrangements for supporting residents to maintain contact with their friends and family were satisfactory. The relationships between staff and residents were good and personal support was provided in such a way as to promote and protect residents’ privacy and dignity. The meals in the Home were satisfactory and provided residents with a varied diet. EVIDENCE: Each person was supported to take part in a range of activities in a various settings. Use was made of local resources such as day centres, colleges and other places of interest. Residents were also given individual support to go to places such as pubs and restaurants. They also took part in art therapy and aromatherapy sessions. The plans of care for each person included how they would be supported to be involved in their local and wider community. Residents could access places in DS0000000648.V302831.R01.S.doc Version 5.2 Page 13 the local and wider community through the use of the Home’s own car. On the day of the inspector’s first visit to the home three people had been on an outing to Tynemouth and two others had been to a local airfield. Staff supported residents to keep in touch with relatives and friends who were important to them. Relatives were consulted about what happens in people’s lives. The residents had opportunities to mix with people who do not have disabilities through the use of what the local community has to offer. The relative of one person said that: “… staff welcomed them in the home at any time” and “…kept them informed of important matters affecting their relative”. There was clear written guidance for staff regarding how they should respect and safeguard the residents’ right to privacy. Staff were observed following this guidance. The Home’s menus were varied and indicated that residents were offered a healthy and nutritious diet. Alternatives were available and healthy eating was encouraged. Residents were encouraged to assist with the food shopping and, where appropriate, the preparation of meals. Because of the size of the kitchen/dining area staff took their meals after the residents had eaten theirs. DS0000000648.V302831.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Suitable plans of support were in place and staff had a good understanding of each resident’s support needs. The arrangements for monitoring and meeting the health care needs of residents were satisfactory. This meant that people received the health care and support they needed. The arrangements for the administration and recording of medication were also satisfactory and protected the residents. EVIDENCE: DS0000000648.V302831.R01.S.doc Version 5.2 Page 15 In their response to a questionnaire all of the residents said that staff ‘treat them well’. Both social workers confirmed that they were satisfied with the overall care provided to residents. One said: “Prudhoe House staff have always maintained a good standard of care in my opinion”. Support plans were in place for each resident describing how their personal and general care needs and preferences would be met. Residents were supported to make choices about their daily lives and routines. Staff also supported and assisted the residents to choose their own clothes, hairstyles and toiletries. The health care needs of the residents had been assessed and were recorded in their plans of care. Their health care needs were monitored and regularly reviewed. Each resident was registered with a local GP. Residents were supported to access health care services such as dentists, opticians and, where appropriate, specialist services such as occupational therapists. None of the residents were responsible for administering their own medication. No problems were noted in the sample of medication records examined. A lockable storage facility was available for the safe storage of medication. Nine of the staff responsible for administering medication to residents had had training in the safe handling and use of medicines. Training was being arranged for the three staff who hadn’t DS0000000648.V302831.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Suitable systems were in place for handling complaints and for protecting residents from abuse. This meant that the views of residents and their relatives or representatives were listened to and acted upon and residents were protected from abuse and neglect. EVIDENCE: The Home had a complaints procedure. This was available in a format that could be understood by some of the residents. With the support of staff, 5 of the residents confirmed in their response to a questionnaire that they knew how to make a complaint. The key worker for one resident explained that this person would be unable to follow the complaints procedure, but they had full confidence in their carers who would follow up anything that may warrant a complaint. There were no entries in the Home’s Complaints Record Book. Both social workers said they had not received any complaints about the Home. The relative of one resident said they had made a complaint and that this had been dealt with promptly and to their satisfaction. Because of a misunderstanding on the part of the Manager this complaint had not been recorded in the Home’s Complaints Record Book. The majority of staff had received basic training in the protection of vulnerable adults. This is now part of the regular core training for staff. Policies and procedures for the protection of vulnerable adults were in place. There had been no incidents that had required a referral in line with these procedures. DS0000000648.V302831.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 29 & 30. Quality in this outcome area was adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The arrangements for keeping the Home clean and tidy were satisfactory. The standard of the accommodation, décor and furniture and fittings was in general adequate and provided residents with a comfortable place to live. The arrangements for the provision of specialist aids and equipment to meet the needs of all the residents were not fully satisfactory. Prompt action had not been taken to provide equipment to meet the assessed needs of one resident. EVIDENCE: DS0000000648.V302831.R01.S.doc Version 5.2 Page 18 The Home was clean and tidy. Staff had put effort into giving it a homely appearance. There was a lift as well as stairs and most parts of the premises were accessible to all of the residents. The Home is situated close to local amenities and public transport. Maintenance and redecoration is carried out at regular intervals. Residents are supported to personalise their bedrooms. There was a room where residents could see visitors in private. Staff said the Home would benefit from having a shower room and a larger kitchen. Two of the residents shared a bedroom and none of the bedrooms had en-suite facilities. Staff said one of these residents preferred not to share. The Home had a number of items of specialist aids and equipment to meet the needs of the residents. New hoisting equipment had been installed for one person so that their moving and handling needs could be better met. But an occupational therapist had been involved in assessing the moving and handling needs of one resident who was at risk of falling. They had recommended, in a letter dated 5 July 2006, that additional moving and handling equipment be provided for the person concerned, because the Home’s mobile hoist could not be used in their bedroom due to the limited floor space. This had not yet been done. The Manager said that this equipment had only recently been ordered. The ‘Falls Risk Assessment’ for this person, dated December 2004, said that if staff could not use a hoist to assist this person, following a fall in their bedroom during the night, they were to be made comfortable until staff came on duty in the morning. The Manager said she would consult with this person’s occupational therapist and care manager about the assessment and the guidance to staff. Cleaning materials and other potentially hazardous substances were safely stored. Policies and procedures were in place relating to the Control of Hazardous Substances and Infection Control and other Health and Safety matters. Staff received regular Health and Safety training including Food Hygiene. DS0000000648.V302831.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34 & 35. Quality in this outcome area was adequate. This judgement has been made from evidence gathered both during and before the visit to this service. There was a competent team of staff who had access to a range of training opportunities. This meant that people were being cared for by staff who had had relevant training in meeting their care needs. Staff records were not kept in the Home as required. This was not satisfactory since it meant they were not readily available for inspection. EVIDENCE: Staff were observed communicating with and supporting residents in a caring, respectful and helpful manner. It was evident that the residents felt comfortable in their company. Staff said they felt there was always sufficient staff on duty to meet the needs of the people who live at Prudhoe House. Three staff are now on duty each Sunday to support people to go out on activities and outings. The relative and two social workers who completed a questionnaire all confirmed that they were satisfied with the overall care provided to residents. There was a programme of training for staff that included regular updates of core training. The training programme for 2007 – 2008 included Equality and DS0000000648.V302831.R01.S.doc Version 5.2 Page 20 Diversity and Person Centred Planning. Eight of the eleven care staff had a relevant professional qualification. Two inspectors made an announced inspection visit to the personnel department of Northgate and Prudhoe Trust. This was because all of the staff records are held centrally and have not been inspected for some time. Twenty staff files were made available from a selection of homes within the area. The inspectors also requested six specified home files on the day of inspection. The files were comprehensive. There was evidence of Criminal Record Bureau checks, health questionnaires, completed application forms and confirmation of employment. Where possible service users have been involved in the recruitment process. The files also contained details of a six-week induction, probationary period and individual training and development profiles. There was evidence from the interview sheets that prospective staff have to supply proof of identity and proof of training. This information is not collated on to the files. Staff said that photographs and copies of training certificates were going to be put on the files but this has not started. DS0000000648.V302831.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 & 42. Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to this service. The Manager was suitably qualified and she had the knowledge and experience needed to care for people who have learning disabilities and to manage a care home. The arrangements for monitoring the quality of the service at Prudhoe House were not satisfactory. They did not ensure that the views of residents, their families, friends and relevant people in the local community are sought about the service provided and how it should be developed. Steps had been taken to keep the residents safe but the arrangements for protecting people from the risk of fire were not fully adequate. EVIDENCE: The Manager is a registered nurse with significant experience of working with people who have learning disabilities and managing a community home. She also has a relevant management qualification. There was evidence that she DS0000000648.V302831.R01.S.doc Version 5.2 Page 22 regularly updated her training and reviewed the care practices within the home. A quality assurance and quality monitoring system was in place. However, the records available indicated that the system had not been fully implemented during the previous 12 months. Monitoring visits to the Home had not been carried out each month as required. There were only four reports available in the home for the previous 12 months. Staff received regular training that covered moving and handling, health and safety, first aid and basic food hygiene. Risk assessments were in place covering safe working practices. Regular ‘in house’ checks of the Home’s fire equipment were being done. Records indicated that some staff had not taken part in a fire drill during the previous 12 months. It was difficult to get an overview of this because individual records were not being kept for each person. Some staff said that if there was a fire in the home the procedure was for residents and staff to ‘stay put’ in the building. The Manager said this was not the case. Checks had been carried out on the Home’s shaft lift, electrical equipment and gas and electrical installations. There were no records available to confirm that the required six monthly check of the Home’s hoisting equipment had been carried out in July 2006. The Manager said they had. DS0000000648.V302831.R01.S.doc Version 5.2 Page 23 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 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 2 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 2 X DS0000000648.V302831.R01.S.doc Version 5.2 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 13 & 14 Requirement The Registered Person must ensure that residents’ assessments and plans of care are kept under review and updated where necessary. Ensure that a record is kept in the home of all issues raised or complaints made by service users to include details of the investigation, action taken and outcome. Where a service user, because of their physical disability has been assessed as requiring special aids and equipment ensure that this is provided promptly. The Registered Persons must ensure that at all times records are available for inspection in the care home by any person authorised by the Commission to enter and inspect the care home. The registered Person must establish and maintain a system for: a. reviewing at appropriate intervals; and b. improving, the quality of care provided at the Home. DS0000000648.V302831.R01.S.doc Timescale for action 12/03/07 2. YA22 22 19/02/07 3. YA29 23 12/03/07 4. YA34 17(3)(b) 12/04/07 5. YA39 24 19/04/07 Version 5.2 Page 25 The Registered Person shall supply to the Commission a report in respect of any review of the quality of care provided at the Home and make a copy available to service users. The system for reviewing the quality of care provided at the Home must provide for The Registered Person must take 12/03/07 action to ensure that monthlyunannounced visits are carried out at Prudhoe House in accordance with Regulation 26 of the Care Homes Regulations. The person carrying out each visit must prepare a written report on the conduct of the home. The Registered Persons must 12/03/07 ensure that all staff take part in fire drills at the frequency agreed with the Fire Authority. 6. YA39 26 7. YA42 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA23 YA34 YA42 Good Practice Recommendations In order to ensure that all service users are protected from harm it is recommended that staff have Criminal Record Bureau checks carried out at 3 yearly intervals. In order to improve the monitoring of staff participation in fire drills and fire prevention training it is recommended that individual records be kept for each member of staff. Copies of maintenance checks/inspections of the Home’s installations and equipment should be available in the Home for inspection. DS0000000648.V302831.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000000648.V302831.R01.S.doc Version 5.2 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!