Inspection on 24/01/06 for Shadon House

This inspection was carried out on 24th January 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Shadon House 26/01/09

Shadon House 12/12/07

Shadon House 30/08/06

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 Miss Nic Shaw Unannounced Inspection 09:00 24 & 27 January 2006 th th 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.V267861.R01.S.doc Version 5.1 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.V267861.R01.S.doc Version 5.1 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 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.V267861.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th August 2005 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 11 permanent service users whilst 12 of the beds are available to people who wish to stay in the home for a short break. 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 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, including Dobbies garden centre are located a short distance form the home. Shadon House DS0000038099.V267861.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two days in January 2006, took approximately 13 hours to complete and was a scheduled unannounced inspection. The inspection process involved talking to the manager, five staff, approximately eleven service users and one visiting professional. A sample of records were viewed and a tour of the building took place. Service users were joined for lunch and tea and observations were made of the support the staff offered to service users during mealtimes and throughout the day. The judgements made are based on the evidence available on the day of the inspection. What the service does well: There are very good, clear assessment procedures in place so that service users know that their needs will be met when staying at Shadon house. There is good contact maintained with other professionals, such as social workers, and this helps to ensure that the service provided remains appropriate. The accommodation provides the service users with a “homely” comfortable environment in which to live as well as offering specially adapted aids, adaptations and facilities which assist people with dementia to remain independent. The staff and manager are well trained in the area of dementia and have time to sit and chat with the service users. The atmosphere is warm, welcoming and friendly and the manager offers a clear sense of direction and guidance to staff. The food provided is of a good quality with plenty of choices available to the service users. Each day in the home there are activities available. These range from in house activities such as decorating mugs, which were displayed around the home, to outings to the local pub and tea dances. The staff and manager take an active role in educating the local community on dementia, as well as raising the profile of Shadon House, by visiting local schools and providing talks to the children on this subject. The daily routines of the home are flexible. This means that the service users can have meals when and where they want, can choose to spend time on their own or with other people, and can enjoy a lie in bed in the morning. Shadon House DS0000038099.V267861.R01.S.doc Version 5.1 Page 6 All of the service users spoken to said that they liked the staff and throughout the inspection the staff included the service users in discussions and activities. There was much laughter and smiling and this adds to the pleasant atmosphere within the home. There are no locked doors in the home. This means that service users can choose to leave the building and freely access the spacious garden. Staffing levels are provided to ensure the safety of the service users where it has been identified that leaving the building without staff support is a risk. The manager and staff have many ways of involving the service users in the running of the home. These include regular service user meetings as well as service user satisfaction surveys. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Shadon House DS0000038099.V267861.R01.S.doc Version 5.1 Page 7 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.V267861.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Each service user’s needs are assessed prior to their move to the home. This helps to ensure that each service user’s needs are met at the home and inappropriate admissions are avoided. The home does not provide Intermediate Care. EVIDENCE: Each service user has a social worker’s assessment undertaken prior to their admission to the home. The manager also carries out an individual assessment. The assessment tool used varies depending on whether a service user has been placed in the home for a full assessment, for a short break or they are to move into the home on a permanent basis. It was evident from those care plans examined that the assessment process continues throughout a service users stay. The “mini mental health” assessment tool is used to assess if there has been a progression in a service users dementia and this is completed for the permanent service users on a three monthly basis and more frequently for those people placed in the home specifically for the purposes of assessment. In addition to this the “well being ill being” assessment tool is used where a change in a person’s behaviour has been observed. Shadon House DS0000038099.V267861.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 The measures staff take to support the health and personal care needs of service users is not always fully recorded in the individual plan of care which may therefore make it difficult for staff to consistently meet their needs. Appropriate systems for storing and administering service users medication are in place, however, some improvements need to be made to the administration and record keeping procedures in order to minimise the risk of errors occurring and to ensure that the service users receive the medication for which they have been prescribed. Arrangements are in place to help preserve service users privacy and dignity. EVIDENCE: A range of care plan documents are currently in use. The manager and senior staff are in the process of reviewing the quantity and quality of these with a view to developing a format that is easy to follow providing staff with clear guidelines on the actions needed of them to meet the service users assessed needs. The level of detail varied in those care plans examined. In one file a service user was described as having “good days and bad days”. Advice was offered to include information on what this means for the service user including Shadon House DS0000038099.V267861.R01.S.doc Version 5.1 Page 10 details of interventions needed of the staff should this service user be experiencing a “bad” day. A number of service users benefit from “doll therapy” and the staff described in detail how and when dolls were used in this way. However, this positive work was not always documented in the care plan. In one care plan examined it was good to note that there was a focus upon a persons strengths and abilities, what the service user could do as opposed to what they needed support with. The information recorded in this care plan was of a good standard which included details of how to communicate with the service user. Staff spoken to were clearly knowledgeable of the service users strengths and abilities and potential areas of risk, such as leaving the building and smoking. Advice was offered to ensure that where risks have been identified risk management plans need to be developed to advise staff of action needed of them to minimise the risk. These should also include techniques used by staff to distract service users from becoming agitated, which was observed in practise. Separate night care plans are in place, which for one service user includes providing them with the opportunity of spending time in the snoezelen room during the night if they are awake. Staff are also engaging the service users in life story work and this involves spending time talking to people about their past histories. This information is then recorded into a “pocket book of memories” which is kept in the service users bedrooms. Service users spoke positively of the staff and confirmed that their health care needs are met in the home. A record of contact with GP’s, District Nurse and other health care professionals, such as the falls assessor and physiotherapist are maintained. A nutritional assessment is not completed for those service users who use the short break service. The manager agreed that this should be carried out for all service users in order to ensure that their nutritional needs are met whilst staying at Shadon House. The home encourages people to look after their own medication where they are capable of doing so. The manager described a service user, who was staying at Shadon House for a short break, who had an alarm to remind them of when to take their medication and in this way they were able to maintain their independence. However, all current people staying at Shadon house have their medication managed by the staff. Staff who are responsible for looking after the medication have had training in this area. For permanent service users a pharmacist delivers medication to the home, mainly in a monitored dosage system. Medication is stored securely in a locked trolley in a locked room. Medication records include the name, medication type and a recent photograph of each service user, so that staff know who the medication is for. Shadon House DS0000038099.V267861.R01.S.doc Version 5.1 Page 11 An examination of the medication records identified a number of issues. For example; in one instance records indicated that a service user had not received their prescribed medication. In another situation the medication records had not been completed correctly and could be misleading for staff, which in turn could increase the risk of medication errors occurring. These issues were discussed with the manager during the inspection and an immediate requirement notification was issued in relation to this. The manager has since written to the Commission for Social Care Inspection to confirm that she has carried out a full audit of all medication held in stock and taken action to rectify any further issues identified as a result of this. It was clear from observations and discussions that service users are treated with respect and dignity and that any personal support is provided in the privacy of their own rooms or in bathrooms. All service users have a telephone in their bedroom, there is also a telephone booth located along one corridor, so that they can make and receive calls in private. Shadon House DS0000038099.V267861.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13 & 15 People who live and stay at Shadon House are offered many opportunities to take part in a range of activities, to follow their interests and ambitious and to maintain good contact with their families. This enables them to lead active fulfilled lifestyles. Tasty, proficiently cooked meals are provided with many choices available, offering a good balanced diet, which contributes to the promotion of healthy eating. EVIDENCE: An activities programme was on display throughout the home. On the morning of the inspection staff were engaging service users in a sing along/dance session and observations indicated that the service users thoroughly enjoyed this activity which also encouraged exercise and movement. A social worker who was visiting the home at this time confirmed that this was “the norm” and whenever he visited the home there was always lots for the service users to do. As well as activities provided in the home, which includes arts and crafts, baking sessions, fashion shows and visits by the local priest and members of a local church, service users are provided with the opportunity of outings in the local community. These include trips to the local club, Metro Centre and plans are in place for some of the service users to attend a local tea dance. Service Shadon House DS0000038099.V267861.R01.S.doc Version 5.1 Page 13 users benefit from the snoezelen room which is equipped with a range of sensory equipment including fibre optic lighting. Staff spoken to confirmed that activities are available for the service users during the night and for one service user spending time in the snoezelen room when they are unable to sleep forms part of their plan of care. Local celebrities also visited the home for the official opening and photographs of this occasion were on display in the corridors. Throughout the inspection there was a steady stream of visitors to the home. It was evident that the manager and staff have a good rapport with relatives and encourage them to take an active role in their family members care. For one relative this involves assisting their family member with their personal care each morning. The manager also arranges support groups for relatives and this extends to the provision of a “surgery” when a range of professionals are available in Shadon House for relatives to meet and talk with. As mentioned earlier in the report life story work is carried out with the service users. During the inspection staff demonstrated that they take time to talk and are motivated to engage and communicate with everyone living at the home. Staff were also seen to be courteous and approachable in their contact with relatives. Service users commented that the quality of the food is good, that they enjoyed the cooked breakfasts available and that they have a good choice of meals. The lunchtime and evening meal was taken with the service users and this was observed to be a pleasant social occasion. The cook always ensures that he obtains feedback from the service users on the quality of the food provided by attending service user meetings. Discussion with him also confirmed that he involves the service users in baking sessions as well as providing cake decorating demonstrations. Discussion with the cook confirmed that he was knowledgeable of the needs of different ethnic minority groups and has been provided with training in relation to this. Separate food storage facilities are available should this be required. Shadon House DS0000038099.V267861.R01.S.doc Version 5.1 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The home has a satisfactory complaints system. However, the complaints procedure is not available in a format suitable for those people who have a visual impairment, which may prevent some of the service users from expressing their views. EVIDENCE: The Social Services Department has a corporate complaints procedure and this was on display in the foyer of the home. However, in order to meet the requirement of regulation 22(6) this document must be made available in a suitable format for those service users who have a visual impairment, as currently it is only available in small print. It was also advised that the development of a more “user friendly” simplified version of the complaints procedure would be more accessible and appropriate to people with dementia. There have been no complaints made to the manager since the last inspection. However, in discussion with the manager and staff it was evident that on a day to day basis they deal with “gripes and concerns” raised by relatives and service users. Advice was offered that a record of these, together with action the manager has taken to address them, should be maintained as further evidence that service users views are listened to and acted upon. Shadon House DS0000038099.V267861.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26 The home is clean and hygienic. EVIDENCE: The areas of the home that were examined during this visit were clean and hygienic. There is a separate laundry area, away from service users accommodation, which is well equipped. There is a policy and procedure file available to staff in the office on infection control and all staff have received training in relation to this issue. Throughout the inspection staff were observed to wear protective gloves and aprons where appropriate and alcohol hand wash as well as liquid soap is provided throughout the home. Shadon House DS0000038099.V267861.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 The deployment and number of staff on all shifts ensures that at all times service users are supported by an experienced group of staff, however, the number of catering hours needs to be reviewed to ensure that standards relating to nutrition and meals are maintained. EVIDENCE: There are sufficient staff available to meet the needs of service users at the home. Staff were noted to spend time listening to the views and experiences of the service users, taking part in discussions with them and demonstrating good humour as well as an in-depth understanding of the needs of people with dementia. It was positive to note that the manager has the autonomy to increase staffing levels depending upon the needs of the service users, particularly in those situations where it has been identified that a service user may leave the building without staff support and be at risk of becoming lost or hurting themselves. All of the service users spoken to said that they liked the staff. There is one full time head chef, who works 37 hours per week, and a second cook who works 15 hours per week. This means that on some days there is only one cook on duty who is responsible for the provision of all of the meals, including ensuring the cleanliness of the large kitchen facility. It is recommended that this be reviewed to ensure that this is sufficient for the number and needs of service users and nature of the service provided, which also includes the provision of day care. Shadon House DS0000038099.V267861.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 &38 Effective quality assurance systems are in place so that service users and their relatives know that their views will be listened to. Robust procedures are in place which safeguard the service users financial interests. The service users health and safety is generally promoted and protected, however, some improvements need to be made in this area. EVIDENCE: There is a comprehensive quality assurance system in place entitled “CARED 4”. This involves the regular monitoring and evaluation of the homes policy statements to ensure that standards set are achieved and records are maintained of this. Examples of regular audits carried out include monthly health and safety checks. Feedback is also obtained on the service provided from service users and their relatives by means of questionnaires and service user meetings. Shadon House DS0000038099.V267861.R01.S.doc Version 5.1 Page 18 A sample of service users personal allowance records maintained by the home were examined. For each purchase made by the staff, on behalf of the service user, receipts and two staff signatures are maintained. Secure facilities are provided for the safe-keeping of money and valuables on behalf of the service users. The temperatures of the bath and shower water was tested at all outlets and in two instances was found to be in excess of the recommended 43 degrees centigrade and in one case was found to be as high as 52 degrees centigrade. An immediate requirement notification was issued in relation to this. The manager has since confirmed that this issue has been addressed. Records examined confirmed that fire alarms are tested weekly and that all day staff have received a six monthly fire instruction. However, there is a need for nightstaff to be provided with a fire instruction/drill every three months. In order to promote the managers “open door” style of management the office door, which is a fire door, is kept wedged open. All fire doors must be kept shut and discussion with the manager confirmed that it is her intention to purchase a magnetic door guard for this door. A record of accidents is maintained and systems are in place to monitor the occurrence of these for those people who have been assessed as at risk of falling. Guidance has been sought from the falls prevention officer where this has been identified as a need. Due to the high number of accidents which have occurred it was suggested that the manager also implement a system to monitor if, for example, there are specific times when these occur, as this may have an impact upon the staffing levels provided at particular times of the day. Shadon House DS0000038099.V267861.R01.S.doc Version 5.1 Page 19 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 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X X X X X X X X 3 STAFFING Standard No Score 27 2 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 2 Shadon House DS0000038099.V267861.R01.S.doc Version 5.1 Page 20 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 OP7 Regulation 15(1) Requirement Timescale for action 30/06/06 2 OP8 12(1)(a) 3 OP9 13(2) 4 OP16 22(6) Care plans must continue to be developed as discussed in the body of the report. These should include detailed risk management strategies for all areas of risk identified through the assessment process. A nutritional assessment must be 31/03/06 carried out for those service users using the short break service. Medication records must be 27/01/06 completed correctly in order to minimise the risk of medication errors occurring. Service users must receive the medication for which they have been prescribed. The complaints procedure must 31/03/06 be made available in a format suitable to those people who have a visual disability. Nightstaff must receive a fire instruction/drill every three months. Fire doors must not be wedged open. Bathwater and shower DS0000038099.V267861.R01.S.doc 5 6 7 OP38 OP38 OP38 23(4)(e) 23(4)(a) 13(4)( c ) 27/01/06 27/01/06 27/01/06 Page 21 Shadon House Version 5.1 temperatures must be maintained at 43 degrees centigrade.(Timescale not met 26/08/05). 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 OP27 OP38 Good Practice Recommendations A review of the catering hours allocated to the home should be carried out to ensure that these are sufficient. A system should be implemented to monitor the occurrence of accidents in order to determine whether any further action can be implemented to reduce the frequency of these. Shadon House DS0000038099.V267861.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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 Shadon House DS0000038099.V267861.R01.S.doc Version 5.1 Page 23 - 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!