Inspection on 05/06/08 for Prudhoe House

This inspection was carried out on 5th June 2008.

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

Prudhoe House 24/06/07

Prudhoe House 19/11/06

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 28/09/2008.

CARE HOME ADULTS 18-65 Prudhoe House South Road Prudhoe Northumberland NE42 5LB Lead Inspector Elaine Charlton Key Unannounced Inspection 5th June 2008 10:15 Prudhoe House DS0000000648.V363904.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 Prudhoe House DS0000000648.V363904.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. Prudhoe House DS0000000648.V363904.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 NTAWNT.prudhoe@nhs.net 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 Prudhoe House DS0000000648.V363904.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th June 2007 Brief Description of the Service: Prudhoe House is a registered care home for six people who have learning disabilities, and is situated within the community of Prudhoe. The home is an attractive listed building and blends in with the local community. There are four single bedrooms and one double and a passenger lift is installed to help people get to the first floor. It is close to local shops, amenities and transport networks. There is an attractive garden area to the front of the building and off street parking. Nursing care is not provided. Fees are £947 per week. Copies of the home’s statement of purpose and the Commission for Social Care Inspection (CSCI) reports are available. Prudhoe House DS0000000648.V363904.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star, this means that the people who use this service experience good quality outcomes. An unannounced visit was made on the 5 June 2008, with further follow up visit on the 20 June. A total of 7 ¾ hours were spent in the home. The inspection took place over two days so that routines and planned events were not disrupted. The manager was present during each visit. Before the visit we looked at: Information we have received since the last visit on 24 June 2007; How the home has dealt with any complaints and concerns since the last visit; Any changes to how the home is run; The provider’s view of how well they care for people; Annual Quality Assurance Assessment (AQAA). The AQAA gives CSCI evidence to support what the agency says it does well, and gives them an opportunity to say what they feel they could do better and what their future plans are; The views of people who use the service, their relatives, staff and other professionals who visit the service; Sent “Have your say” questionnaires for residents, who were able, to complete, relatives and staff. During the visit we: Talked to people living in the home, staff, and the manager; Looked at information about the people who use the service and how well their needs are met; Looked at other records which must be kept; Checked that staff had the knowledge, skills and training to meet the needs of the people they care for; Looked around the building/parts of the building to make sure it was clean, safe and comfortable; Checked what improvements had been made since the last visit; We told the manager what we found. What the service does well: Gets information about the needs of people before they can move into the homed so that everyone is sure their needs can be met. Consult with and follow the advice of health and social care professionals to ensure that people living in the home get the right care and support and that their needs are kept under review. Prudhoe House DS0000000648.V363904.R01.S.doc Version 5.2 Page 6 Promote contact with families and make sure that people get the chance to visit their relatives and spend time with them. Deliver care and support in a sensitive, private and caring way. This means that people who live in the home are properly supported and valued. Provide staff with training and support so they are able to meet the needs of people living in the home. This means that residents and staff are kept safe. When asked what the home did well a relative said: “Caring for my relative and other clients”. When asked what the home does well staff said: “Provides a high quality of care for all our service users using our experience and skills. The trust provides training to enable us to do this. Regular information is cascaded down to all staff re position of trust and what is happening in our division”. Another comment was: “I am happy to be working in a community environment and feel I give a high standard of care to our service users”. The manager and staff co-operated throughout the inspection and were able to provide everything we asked for easily. What has improved since the last inspection? What they could do better: Adopt a more person centred approach to care planning so that individual needs are properly and clearly identified. Records should be regularly reviewed to make sure they meet changing needs. Review and update risk assessments and guidance so that staff are clear what the current support needs of residents are. This will help to keep people living in the home safe. Prudhoe House DS0000000648.V363904.R01.S.doc Version 5.2 Page 7 Review the kitchen plans and put in place changes to meet the needs of people living in the home and staff. This will mean that people can be properly supported at meal times. When asked what the home could do better staff said: “Sometimes I feel all staff need individualised training for the needs of the service user ie., autism, epilepsy etc.” “More training on individual needs, make things happen quicker, nothing gets done quickly, can be a slow process for certain things”. “Employ more staff. Have less paperwork and more hands on”. 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. Prudhoe House DS0000000648.V363904.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 Prudhoe House DS0000000648.V363904.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): Standard 2. People who use the service experience good quality outcomes in this area. People are given good information to help them decide about moving into the home. Their needs and wishes are fully assessed so that everyone is sure they can be met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Everyone who lives in the home moved in several years ago. Each person’s needs were assessed before their admission to Prudhoe House and there have been no new admissions since the last inspection. The home’s statement of purpose says that people will only be admitted to the home following receipt of a full Social Services needs assessment. One relative sent back our “Have your say” questionnaire. They told us that they always got enough information and were kept up to date with important events. When asked what the home did well they said: “Caring for my relative and other clients”. Prudhoe House DS0000000648.V363904.R01.S.doc Version 5.2 Page 10 The Trust has a statement of confidentiality with partner agencies that covers the guidelines for sharing information about people who live in the home. Prudhoe House DS0000000648.V363904.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): Standards 6, 7 and 9. People who use the service experience adequate quality outcomes in this area. People who are able are involved in care planning and making decisions and choices about their life but care plans are not person centred. This may not always promote their independence and self-esteem. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: A relative told us that residents’ needs were always met, they were helped to keep in touch and received the care and support needed from staff that have the right skills and experience. The manager told us that a working group within the Trust is looking at person centred planning, support plans and training to support these changes. We looked at the files for two people living in the home. Support workers carry out and record a monthly ‘file audit’ and look at timetables of opportunities, activities and appointments. Prudhoe House DS0000000648.V363904.R01.S.doc Version 5.2 Page 12 They also complete a monthly summary that covers health, social life, activities, relationships and progress. The summaries are not always completed each month. There are a limited number of care plans in each persons file but they are not person centred. People who are able, make clear choices about what they want to do, where they go, what they wear and how they spend their time. Those who are less able are helped by staff that have known them for a long time. We saw recordings that showed whether a person could help in planning their care or not. Where someone was not able the reason for this was recorded. An aroma therapist visits the home regularly. There was a procedure in place for one resident who has a hands, feet and neck massage, that showed how the person indicated whether they wanted a massage and if they were enjoying this or not. Risk assessments are in place but they have not all been regularly reviewed or updated. Some are still in place but are no longer relevant. There are individual fire evacuation plans in place for each person and staff sign to say they have read and understood these. One record showed that a person needed two to one support when they were outside the house. This did not clearly show that this was only necessary when the person was walking and that they only needed one to one support if they were using a wheelchair. Staff had been provided with guidelines to manage behaviours that some residents may display. These had last been reviewed in July 2005. In one set of guidelines for ‘challenging behaviour’ the control section said “last resort medication or restraint”. The restraint was not care planned but the manager told us this was no longer an issue and had not been since the person left hospital. The records for both people showed that they had made choices about where they wanted to go. One person is very able and goes out four days a week. Family members have been involved in some decision making processes but no one living in the home has access to an independent advocate. Prudhoe House DS0000000648.V363904.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): Standards 12, 13, 15, 16 and 17. People who use the service experience good quality outcomes in this area. People are able to live the life they choose promoting their independence and work opportunities. These choices and opportunities are only restricted by a person’s wishes and their abilities. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Through records and speaking to staff we were able to see that people get the chance to do things they want and, where they are able, attend courses and go to work. One person goes to Cancer Bridge two days a week where they work preparing baking for sale to the public. This is something they really enjoy and look forward to. Prudhoe House DS0000000648.V363904.R01.S.doc Version 5.2 Page 14 Support workers take the time to go and see whether ‘sessions’ at the local leisure centre would be appropriate for people living in the home. They are always looking to see if they can find new things for people to do. Opportunities are only limited by a person’s level of ability. On the first day of the inspection one person had gone out with a member of staff to the Metro Centre. We were told that people enjoy shopping, eating out and going to shows. They had seen Chitty Chitty Bang Bang at Sunderland and Boyzone at the Metro Arena. Everyone has an individual ‘holiday’ budget from the Trust that they can spend in a way that best meets their needs. One person was going for a long weekend at the Calvert Trust at Kielder supported by staff. Arrangements had been made for them to make the trip through Weardale where they could visit family and have lunch out. This was a very sensitive arrangement that the family appreciated. People are helped to keep in touch with family who are also welcome to visit the home. One person speaks to their parent everyday by telephone and visits them regularly. Routines in the home are flexible and staff were seen attending to residents in a sensitive and private way. Staff promote a healthy eating programme and menus are planned taking into account the known likes and dislikes of people living in the home. There are difficulties with the size of the kitchen and mealtimes when everyone is at home. The manager told us that staff know what each person living in the home likes, how long it takes them to eat their meal, those who should be encouraged to take a little more time over their meal and the size of plate to give them. These considerations reflect individual choice and respects people’s need not to be ‘over faced’ with food. Advice has been sought and acted upon to meet the changing needs of a resident who now needs to have their food pureed or mashed to prevent choking. Prudhoe House DS0000000648.V363904.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): Standards 18, 19 and 20. People who use the service experience good quality outcomes in this area. People living in the home and who can make their own choices are asked how they wish their personal care to be provided and by whom. They are supported and helped with their medication and can see health care professionals when they need. Good routines for administering medication and in place and records are kept up to date keeping people safe. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: We saw evidence of people’s needs being assessed and records made of how they want or need their care to be provided. Staff rotas are organised to ensure that both male and female staff are on duty at the same time. One person was seen being given very sensitive support after having a bout of diarrhoea when sitting in the lounge. Their dignity was maintained at all times. Records show that people see a range of healthcare professionals and social care professionals as and when they need. Prudhoe House DS0000000648.V363904.R01.S.doc Version 5.2 Page 16 Reviews were taking place on the first day of the inspection and a Consultant and care manager were attending to look at the changing needs of a resident. The medication needs for two residents had been reviewed and for one person this is being followed up bi-monthly to make sure that the changes were appropriate. There is equipment available in people’s bedrooms and communal areas to make sure that they can receive their care in a safe and comfortable way. A random check of medication held in the home was carried out. Policies and procedures are regularly followed and medication is kept securely within the home. There are no controlled drugs prescribed at the moment but systems and storage facilities are in place should this be necessary. Two minor recording issues were identified. Medication kept in the home from the previous month had not been carried forward on the Medication Administration Record (MAR), and handwritten entries were not signed by the person making the entry and the person who had checked the entry was correct. Staff have had training in the safe handling of medication. There is guidance available for staff so that they know what the side effects of medication may be, and what to look out for. The Trust has consent to treatment documentation and guidelines for staff. There is a capacity to consent assessment that may need to be reviewed to make sure that it meets the requirements of the Mental Health Capacity Act. People living in the home have differing mobility needs and one person is blind. They cope well with the layout of the home and are able to use toilet facilities and other areas independently. Staff who sent back questionnaires told us that they are always kept up to date with information about people living in the home. A relative told us that the home meets differing needs of the people who live there. Prudhoe House DS0000000648.V363904.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): Standards 22 and 23. People who use the service experience good quality outcomes in this area. The views of people who live in the home are listened to. They are protected from harm through policies, procedures and staff training. Events and incidents are recorded and reported to CSCI. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The Northumberland, Tyne and Wear NHS Trust “How to complain leaflet” can be provided in a range of formats. These include Braille, audio, large print and pictures. A pictorial copy of the leaflet is kept in each residents file. Staff who have worked with the residents when they were in hospital, and since their move to Prudhoe House, know what changes to look for in residents who are not able to tell them that they are worried, or have a concern, that might show that they are unhappy. A relative told us they knew how to make a complaint and were confident that it would be dealt with properly. Staff said they knew what to do if relative or resident raised a concern. No complaints have been received by the home or CSCI. Prudhoe House DS0000000648.V363904.R01.S.doc Version 5.2 Page 18 All staff have had safeguarding adults training and the manager has completed a two day course specifically for managers of services. Two new members of staff are waiting to attend the training. The manager told us that she was also trying to identify some complaints awareness training for all staff. Staff are required to have a Criminal Records Bureau (CRB) check at an enhanced level before they are able to work in the home. Support workers are employed in accordance with the General Social Care Council (GSCC) code of conduct and nurses maintain their registration with the Nursing and Midwifery Council (NMC). Prudhoe House DS0000000648.V363904.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): Standards 24 and 30. People who use the service experience good quality outcomes in this area. People live in a homely environment that meets their current needs but changes to the environment are restricted by its listed building status. The home is comfortable, clean, tidy and hygienic. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home provides a comfortable place for people to live. There are four bedrooms at first floor level and one on the ground floor. It is a grade II listed building and this does cause some problems when the environment needs to be adapted. Bedrooms are very individual, furnished and decorated to a good standard and reflect the different personalities of each person. All windows are fitted with restrictors for the safety of residents and doors are lockable. Prudhoe House DS0000000648.V363904.R01.S.doc Version 5.2 Page 20 Vertical blinds have been fitted in the shared bedroom to provide a privacy screen. A new adapted bath is to be fitted in the bathroom on the first floor. There is no shower other than over the bath and there is no space where one could be fitted. People living in the home all enjoy a bath so this does not cause any problems at the moment. There is a mobile hoist and tracking hoist fitted in the home for people who need this type of support. One bedroom is also used to store the hoist, scales and wheelchairs. This is not ideal but the home has very restricted space for storage. The layout of the kitchen and the furniture in it do cause some problems at mealtimes. There is very little space for people to move around. An occupational therapist visited recently to discuss adaptations and changes to the kitchen area to make it more friendly and usable for staff and people living in the home. The manager and an occupational therapist took one resident to the Chair Shop to get an arm chair that suited the resident’s needs. There is a lovely, wide staircase in the home where staff can walk downstairs side by side with resident. This reduces the risk to both resident and staff. There is also a passenger lift installed. The manager told us that there had been problems with the garden contractors. She was trying to get them to attend more frequently in the summer so that residents can enjoy the area to the front of the house. This is the only outside area for them to sit in. There is a utility room on the first floor where an industrial style washing machine and dryer are installed. The washing machine can be programme to provide different services including a sluice wash. There is an additional washing machine in the kitchen for table cloths and teatowels. The home was clean and fresh on both visits. A domestic assistant is employed in the home for two hours a day, Monday to Friday. When she is on holiday support workers cover these tasks. Prudhoe House DS0000000648.V363904.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): Standards 32, 34 and 35. People who use the service experience good quality outcomes in this area. People working in the home are properly recruited and the residents know they are trained and able to help them with the care and support the need, in the way they want. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The Trust has robust recruitment and selection procedures in place that are properly followed. Staff records are kept in the Human Resources department of the Trust but there is a basic, individual staff record kept in the home for each person. These sheets were in need of updating to meet the protocol agreed with CSCI. Mandatory training in moving and transferring, health and safety, first aid, and fire safety is updated each year. The manager told us she was trying to identify IT training for people who have not regularly used a computer. Prudhoe House DS0000000648.V363904.R01.S.doc Version 5.2 Page 22 Staff have had some training in equality and diversity and conflict resolution. Staff who sent back questionnaires told us that they had been properly recruited and their induction covered most of the things they needed to know. They said that training, relevant to their role, was provided and this helped them to understand peoples’ differing needs. Everyone said they saw their manager regularly. One person said they saw them at supervision but they were “available at all times via telephone or email”. The manager keeps a record of staff training and supervision. Staff said: “Sometimes I feel all staff need individualised training for the needs of the service user ie., autism, epilepsy etc.” When asked what the home does well they said: “Provides a high quality of care for all our service users using our experience and skills. The trust provides training to enable us to do this. Regular information is cascaded down to all staff re position of trust and what is happening in our division”. About what they could do better staff said: “More training on individual needs, make things happen quicker, nothing gets done quickly, can be a slow process for certain things”. “Employ more staff. Have less paperwork and more hands on”. Another comment was: “I am happy to be working in a community environment and feel I give a high standard of care to our service users”. Prudhoe House DS0000000648.V363904.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): Standards 37, 38 and 42. People who use the service experience good quality outcomes in this area. People benefit from living in a well-managed, open and inclusive environment that promotes, and is run, in their best interests. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager is qualified and experienced to run the home and she has an excellent understanding of the individual needs of the residents. She works full time but has no time identified that is only for managerial tasks. We carried out a random check of residents’ monies. No problems were identified. Trust financial transactions books are used to record everything and receipt books are in place. Prudhoe House DS0000000648.V363904.R01.S.doc Version 5.2 Page 24 A member of staff is identified as the ‘responsible person’ each day. They start work at 07:45 am for a handover meeting and sign for keys, monies and medication. This happens each morning and night when staff changeovers take place. As part of their induction staff are able to receive training from the Trusts finance department to make sure that they know how they are expected to keep financial records and what the relevant policies and procedures are. Staff have access to comprehensive policies and procedures within the home. We checked fire and accident records as well as servicing and maintenance arrangements for equipment within the home. All checks were up to date. The Fire Officer has visited the home and reviewed the new premises fire risk assessment. Prudhoe House DS0000000648.V363904.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 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 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 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 3 X X 3 X Prudhoe House DS0000000648.V363904.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 15 Requirement Care plans must be produced in a person centred way so that staff access to all the information they need. This will mean that people living in the home receive all the care and support they need. Previous timescale of 1 December 2008, has not yet expired. 2. YA9 15 Service user plans, guidance and risk assessments must be reviewed and kept up to date. This will mean that people receive care and support in the right way and are kept safe. The layout of the kitchen must be reviewed to make sure that the needs of staff and residents can be properly met. This will mean that people living in the home can have their meals in comfort and be supported by staff. Previous timescale of 1 April 2008, was not met. Prudhoe House DS0000000648.V363904.R01.S.doc Version 5.2 Page 27 Timescale for action 01/12/08 01/09/08 3. YA24 23 01/12/08 4. YA24 23 The garden area must be kept tidy and ready for residents to use. This will mean that they can spend time outside when the opportunity arises. 31/07/08 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 YA7 Good Practice Recommendations Consideration should be given to introducing residents to advocates who may be able to help them make decisions. This will mean that people are given as many opportunities as possible to express their views. The consent to treatment form should be reviewed to make sure that it meets the requirements of the Mental Health Capacity Act. This will mean that choices are properly made and recorded. Staff should carry forward the number of tablets retained in the home from the previous month onto the new MAR, and entries that are handwritten should be double signed. This will mean that people living in the home are kept safe. Update the staff information sheets so that all the information required by CSCI is available in the home. This will mean that people know that staff have been recruited in the proper way and that the manager has access to personal information in the event of accident, injury or ill health. Consideration should be given to the manager having an allocation of supernumerary hours to give her time to complete paperwork and ensure that managerial tasks are properly carried out. 2. YA18 3. YA20 4. YA34 5. YA37 Prudhoe House DS0000000648.V363904.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region 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 Prudhoe House DS0000000648.V363904.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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