Inspection on 12/12/07 for Shadon House

This inspection was carried out on 12th December 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

Shadon House 26/01/09

Shadon House 30/08/06

Shadon House 24/01/06

Shadon House 17/08/05

Similar services:

The Highlands

Blenheim House

1 Lanark Close

Beaconsfield Court Care Home

Ann Charlton Lodge

The Gardens Care Home

Westmoor View Nursing Home

Ashlea Mews Residential Home

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

CARE HOMES FOR OLDER PEOPLE Shadon House Northumberland Place Barley Mow Birtley Tyne and Wear DH3 2AP Lead Inspector Mrs Irene Bowater Key Unannounced Inspection 12th December 2007 08:00a X10015.doc Version 1.40 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 Shadon House DS0000038099.V355964.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 Older People. 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. Shadon House DS0000038099.V355964.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shadon House Address Northumberland Place Barley Mow Birtley Tyne and Wear DH3 2AP 0191 410 2816 0191 411 1209 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) Gateshead Council Position Vacant Care Home 23 Category(ies) of Dementia (23), Dementia - over 65 years of age registration, with number (23), Mental disorder, excluding learning of places disability or dementia (5), Mental Disorder, excluding learning disability or dementia - over 65 years of age (5), Physical disability (5), Physical disability over 65 years of age (5) Shadon House DS0000038099.V355964.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th August 2006 Brief Description of the Service: Shadon House is a Local Authority owned home which can provide personal care for up to 23 people who have dementia, 5 of whom may have mental health needs, and 5 of whom may have a physical disability. The home provides accommodation for some permanent service users, whilst the other beds are available to people who wish to stay in the home for a short break or for an assessment. Nursing care cannot be provided but District Nursing services can be accessed as required. Accommodation comprises of 23 single bedrooms on the ground floor level, all with en-suite facilities and located along three corridors. Assisted bathing and shower facilities are located along two of the corridors and in addition to the three communal lounges, conservatory and spacious dining area; service users have access to a multi-sensory room in which a range of equipment such as fibre optic lighting, soothing music and pleasant aromas are provided. There are two separate hairdressing facilities, kitchen, laundry and a range of staff rooms, including a sleep-in room, the latter being available on the first floor of the home. There is a spacious enclosed garden, fully accessible to service users, and separate car parking facilities are available. Local shops, places of worship and other community facilities are located a short distance from the home. Fees range from a minimum of £66.85 per week for short term care to up to £515.55 for those receiving long term care. Details of all charges are available in the home and terms of residency are explained to individuals. Shadon House DS0000038099.V355964.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Before the visit: We looked at: • Information we have received since the last visit on 24 and 30 August 2006. • How the service 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 • The views of people who use the service and their relatives, staff and other professionals The Visit: An unannounced visit was made on date12 December 2007 An expert by experience was involved in the visit to the home. An ‘expert by experience’ is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. During the visit the expert by experience: Talked to people who use services, staff and management Observed daily life in the service and the interaction between staff and people who use services Look around the premises During the visit we: • Talked with people who use the service, relatives, staff, the manager and visitors • 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 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: Shadon House DS0000038099.V355964.R01.S.doc Version 5.2 Page 6 There are good assessments in place so people who stay at Shadon House know that their needs will be met there. There are very good links with local community groups, such as the Alzheimer’s Disease Society and the manager and staff work hard to make sure that the home is viewed as a positive feature of the local community. The meals provided in the home are good and the staff make sure that people’s right to privacy and dignity is respected. There are good complaints procedures in place so that everyone knows how to make a complaint. It is in is lots of different languages, large print and on tape so that people from many ethnic minority groups and people with a visual disability know what to do to make a complaint The staff have also been trained so that they know what to do if they witness or suspect abuse. The home has been especially designed to help people with dementia remain independent. There is a safe, secure garden, which people can use independently so they can get access to lots of fresh air. Staff training and recruitment is excellent. All staff have been especially trained to work with people with dementia. The manager and staff are enthusiastic and professional. All of the staff makes sure everyone is made welcome and the home is a happy, friendly place. There are excellent procedures in place to make sure that the views of the people are listened to. Everyone has been given training on equality and diversity so that they know what to do to meet the very different needs of everyone who stays there. Everyone spoken to without exception spoke highly of the staff and the standard of care provided at Shadon House. “I think they are doing a very good job.” “At Shadon house A is treated as an individual (they know her needs) and she responds to the care staff there.” “I have no concerns about Shadon house.” “They always keep me up to date with hospital visits etc. “ “I find them approachable and very friendly.” Shadon House DS0000038099.V355964.R01.S.doc Version 5.2 Page 7 “Because of good staffing levels people receive a good standard of care and staff are caring and well trained.” “If they become ill they set medical help straight away. “ “They are clean and cared for and the big thing is that there are very happy and friendly care staff.” “Everything is run really well.” “I cannot offer any suggestions as to improvements, as the present standards are very high.” “X prefers staying indoors at the home, I think she has a feeling of security and contentment in Shadon House.” Comments from the expert by experience have been inserted into the main body of the report. However her overall experience were extremely positive Comments included: “I arrived to a warm welcome and a warm cup of tea” “People were never left alone and their carers were watchful and aware of their every need” “A safe, secure happy and caring home” “Thank you to all the staff who made my visit so enjoyable I wish all homes were like this”. What has improved since the last inspection? Care plans are very detailed about people’s lives. They are clear up to date and completed with the individual and their carers. Medication procedures are followed which promotes residents health. There are activities everyday if people want to join in. All areas of the home are very clean tidy and fresh smelling. The manager constantly reviews the number of staff on duty to make sure individual needs are met. Beds now have castors to stop them moving when sat on. There are good arrangements for supporting people to keep their personal monies in a safe place should they wish to do so. Shadon House DS0000038099.V355964.R01.S.doc Version 5.2 Page 8 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. Shadon House DS0000038099.V355964.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Shadon House DS0000038099.V355964.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good admission procedures ensure that people using the service are provided with the right type of care. EVIDENCE: Four people were chosen to case track. There were comprehensive needs assessments, which had been carried out by care managers. Included in this process were the people who were going to use the service and their carers. The staff also carry out assessments to make that they can meet individual needs. The home offers specialist care for a number of people with dementia and also provides a “short break” service. Shadon House DS0000038099.V355964.R01.S.doc Version 5.2 Page 11 The staff use a range of assessment documents specifically designed for people with dementia such as the “well being and ill being” and “mini-mental tests” tools. These are used not only to make sure that people’s needs can be met but also to identify what they might need to continue to live independently when they return home. Shadon House DS0000038099.V355964.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence gathered both during and before the visit to this service. The health and personal care needs of people are well met by staff who make sure the principles of respect, dignity and privacy are put into practice, EVIDENCE: Each person has a plan of care which is person centred and agreed as far as possible with the individual. The care planning format has been validated by the Alzheimer’s Society and is called “Building on Strengths”. This means the care plans focus on what people can do rather on what they can’t do. Four care plans showed that detailed risk assessments are in place. These include prevention of falls, nutrition, modified Bartel Index, Mini Mental State Examination (MMSE) and “well being and “ill being” assessments. Shadon House DS0000038099.V355964.R01.S.doc Version 5.2 Page 13 The care plans are working documents which are reviewed and updated with the individual and other professionals involved in their care. For example nutritional assessments show that some people are at probable risk. There are diet care plans in place and these have been up-dated to include what action staff should take. Some of these charts did not show what food had been offered or taken. The manager has reviewed and amended these since the inspection so that clear information is now available about people’s dietary needs. Care plans are in place covering such issues as personal care, mobility, daily living and communication. For example staff have taken time to find out about previous life histories including being a “football fanatic” belonging to an operatic society and religious preferences. Care plans are also detailed about people’s preferences. For example one person doesn’t like to mix and another person likes a “drink and a snack during the night.” People living in the home have full access to all health services including, GP’s dental, ophthalmic and chiropody services. The home has good contact with district nursing services and asks the advice of specialist health care professional such as dieticians when required. Medication is stored in a secure location within the home. Locked medication trolleys are used to safely transport the medication around the home. For those people who live permanently in the home the pharmacist dispenses their medication each month in a sealed “blister” pack. People who stay in the home for a short period of time only, staff asks their relatives to bring their medication with them to the home. Staff have had training in safe handling of medication. An audit found no discrepancies. People who are on respite have hand written medication charts, which ensure staff, give the correct medicine at the correct time. These hand written directions did not have two signatures to show that staff had copied the directions accurately. Peoples right to privacy and dignity was promoted by the staff. Staff knew the preferred mode of address, which is recorded in the pre-admission information. There is a telephone booth where people can make and receive telephone calls in private. In addition to this all bedrooms have been equipped with a telephone. Many people are alert, chatty, can express some choices and have a good sense of humour. In this way their emotional well being is being supported by the homes friendly, sociable atmosphere and their interaction with staff and other people living in the home. Shadon House DS0000038099.V355964.R01.S.doc Version 5.2 Page 14 The expert by experience observed: “People loved the staff and vice versa. This was not a performance put on I am convinced this happens every day” The expert by experience spoke to someone who said “They were really happy with the care and had gone on holiday for the first time in ten years and he felt he need not worry about his mother”. Shadon House DS0000038099.V355964.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is excellent. This judgement has been made using available evidence gathered both during and before the visit to this service. Daily life experiences and opportunities to take part in activities and enjoy a balanced diet are excellent and people are consistently supported to keep full control over decision-making in their everyday life. EVIDENCE: There is, an activities programme available and this is displayed within the home. This includes activities such as reading the newspapers, cinema nights with popcorn and ice cream, pie and pea suppers, exercises and “discussions about your interests”. Photographs of some activities, which have taken place both inside and out of the home are displayed. As well as the healthy lifestyle programme, there are positive links with local community groups such as “Equal Arts” and the Alzheimer’s disease Society. Lots of opportunities are provided for people to make choices and to take control over their lives. People are also involved in the care planning and some Shadon House DS0000038099.V355964.R01.S.doc Version 5.2 Page 16 people have signed their plans as evidence of this. People are offered the opportunity of using an advocacy service and some have an advocate. Everyone was in the Christmas spirit. People have been out to an organised Christmas party supported by staff. One person who comes for day care spent most of the day playing the organ for those sitting in the lounge. This was spontaneous with individuals requesting tunes to be played and then joining in a sing a long. People living in the home are offered a good variety of meals and snacks throughout the day. Breakfast choices included cereals, bacon and tomatoes, toast and preserves, tea, coffee and fruit juices. Mid morning and mid afternoon snacks including fresh fruit and drinks were offered. Cold drinks were also available throughout the day in the communal areas. Choices at lunchtime were either roast chicken with stuffing, potatoes, swede and carrots or cheese omelette. Choices for dessert were apple crumble and custard or fresh fruit. Yoghurts and ice cream are always available. Table were nicely set with napkins and individual teapots so that people could help themselves. Where necessary staff assisted in a discreet and sensitive manner. Those who were able to comment were very complimentary about the standard of the catering, for example “the food is always nice” and you can’t fault the meals. Another person said: “You wouldn’t find a better place to be. Good food, good staff and nice and warm” Shadon House DS0000038099.V355964.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. Excellent complaints and protection systems are in place. This makes sure that people are able to express any concern and they are protected from harm EVIDENCE: The complaints procedure is available in a range of different formats including Braille, large print and a number of different languages for example Bengali, Chinese and Polish, in order to meet the needs of people with a visual disability and people from ethnic minority groups. The complaints procedures are displayed in the entrance foyer of the home. Comments from the surveys confirmed that people would be able to make a complaint if they were unhappy about anything. They included: “Staff member explained the procedure. Suggested that the office would be the complaint point.” “I have no need to complain as the service is first class.” Shadon House DS0000038099.V355964.R01.S.doc Version 5.2 Page 18 “The expert by experience spoke to a family member who said he was really happy with N’s care although he had a slight concern about N’ mobility. One complaint has been recorded since the last inspection. This was resolved at home level. Staff said that they have completed training in Safeguarding Adults and were familiar with the Local Authority Adult Protection Procedures. Access to advocacy services is actively promoted. There has been one safeguarding alert since the last inspection, which has been resolved. Shadon House DS0000038099.V355964.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,24,26. Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. The home provides people with a safe, clean well-maintained and comfortable environment, which has been designed to meet the diverse needs of those who have dementia. EVIDENCE: The building offers service users 23 single bedrooms with en-suite facilities, three lounges, two hairdressing facilities, a conservatory and a dining area. The decoration throughout the home has been chosen specifically to assist people with dementia. This includes grab rails and doors painted striking contrasting colours in order that they can easily be seen. Shadon House DS0000038099.V355964.R01.S.doc Version 5.2 Page 20 Walls and floors are also in contrasting colours so that people can easily distinguish between them. There is a vast amount of information displayed throughout the home about past lifestyles and local history of the area. Lighting in WC’s is sensor controlled and automatically illuminates when this area is entered. A multi-sensory area has also been created which provides people with a relaxing, yet stimulating area in which to spend time. Assisted bathrooms and shower areas are clearly labelled and are bright and airy. Corridors have been named after streets in the area, which is good practise in dementia care and gives people a sense of living in a small community. Their bedroom door, in this way, becomes their front door and helps to detract from the notion of people living in a large care home. This also helps people find their own way around the home with just minimal prompting therefore again promoting their indepenance. The expert by experience commented: “Bedrooms are very restful, calm with plenty of personal bits and pieces around which is what I like to see” There are plans to provide a domestic style kitchen so that people can retain independent living skills. There are also plans to provide en-suite facilities in some of the larger bedrooms. There is a spacious garden area, with ramped access, which can be freely explored by the people living in the home. This area is to landscaped further in the near future. The home is bright well lit, clean and smells fresh. There are good infection control procedures in place which staff were seen to follow Shadon House DS0000038099.V355964.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is excellent This judgement has been made from evidence gathered both during and before the visit to this service. Staffing levels and systems around recruitment, selection and training of staff are excellent to meet the range of needs of the people using the service and protect them from harm. EVIDENCE: The staffing levels in the home on a daily basis consist of a manager, deputy manager and four staff in the morning with a senior member of staff and four or five staff in the afternoon and evening. There are two staff on duty overnight with a senior member of staff on call. There are sufficient ancillary staff including domestic, administration, chef and an assistant cook. The expert by experience commented that the “staff are happy and the work got done but first and foremost the people were cared for”. “Staff had their names embroidered on the uniforms so there was no chance of forgetting who you were speaking to “ Staff files showed proof of identity, training records and supervisory development. Shadon House DS0000038099.V355964.R01.S.doc Version 5.2 Page 22 Although not examined during this site visit Enhanced Criminal Records Bureau check and two written references are always sought prior to offering prospective staff member a position in the home. Staff said the training was “excellent”. Training includes principles of care, safeguarding adults, stroke awareness, dealing with behaviours that challenge and dementia care mapping. In addition to the above all of the staff have completed the NVQ level 2 training in care, training in falls prevention, nutrition, continence and Parkinson’s disease. The home is an approved learning environment for Gateshead College. Shadon House DS0000038099.V355964.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. The home is run by a competent manager who makes sure that excellent quality assurance and safety systems are in place. This makes sure that people receive an excellent and safe quality of care. EVIDENCE: The registered manager of this home is currently on long-term sick leave. A registered manager of another service has been brought in to manage the home in his absence. Shadon House DS0000038099.V355964.R01.S.doc Version 5.2 Page 24 The current manager has a wealth of experience and is well qualified to manage this service. Qualifications include, Registered Managers Award, Diploma in Managing Care Services, National Vocational Qualification level 4, Dementia Care Mapping and she has recently received a Post Graduate qualification in Managing Public Services. Throughout the site visit it was evident that the whole team are enthusiastic and work well together to make sure peoples individual needs are always met. Questionnaires are used to gather information on the performance of the service and people staying in the home for a short break or assessment are asked to complete one of these prior to them leaving. Regular meetings are held and any concerns or issues raised are recorded and acted upon. There are excellent quality assurance systems in place, which involves a monthly assessment of the home’s success in achieving the standards outlined in the policy and procedure documents. The line manager also carries out detailed audits of the service each month. In response to these monthly reports the manager prepares an action plan detailing how any concerns will be put right. Age Concern have recently carried out a survey of past and present people who have used the service. The home is looking at the positive things they do and then identify what they should do to make things better for people using the service. This means there is always continuous improvement based on peoples right to be valued and listened to. A check of five peoples money was carried out. There were no discrepancies. All had individual records, which are dated with two signatures, and receipts are available for all transactions. In addition to regular internal audits regular external audits are also completed. The home has a comprehensive range of health and safety polices which make sure everyone is protected as far as possible. Clear up to date records are available. These include fire prevention, slips and trips, safe bathing, and accident recording. Following the site visit the manager has confirmed that all accidents are now being recorded in a book that complies with the Data Protection Act. She has also started to complete monthly accident analysis to examine and track any trends. Staff have completed training in all safe working practices and they carry out weekly health and safety checks. Shadon House DS0000038099.V355964.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 Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 4 X X 3 X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 4 Shadon House DS0000038099.V355964.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO 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 OP9 Regulation 12 17 Requirement The registered persons must make sure that all hand written directions on the Medicine Administration Records has two signatures. This will make sure that there are no errors when transcribing directions. Timescale for action 07/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Shadon House DS0000038099.V355964.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection 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 Shadon House DS0000038099.V355964.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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