Inspection on 14/09/06 for Shian

This inspection was carried out on 14th September 2006.

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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shian 18/11/08

Shian 26/11/07

Shian 01/02/06

Shian 01/09/05

Shian 21/03/05

Shian 29/06/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Shian 1 The Paddock High Spen Rowlands Gill Tyne & Wear NE39 2BD Lead Inspector Miss Nic Shaw Key Unannounced Inspection 14th September 2006 09:30 Shian DS0000007387.V309156.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 Shian DS0000007387.V309156.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. Shian DS0000007387.V309156.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shian Address 1 The Paddock High Spen Rowlands Gill Tyne & Wear NE39 2BD 01207 545 534 01207 549 283 Shian@nap.nhs.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Northumberland, Tyne & Wear NHS Trust Claire Marrs Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Shian DS0000007387.V309156.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st February 2006 Brief Description of the Service: Shian provides ordinary housing for people with learning disabilities, all of whom were formally resident in a long stay hospital. Shian can provide personal care for 3 people. The service cannot provide nursing care. The home is a large detached bungalow situated in a residential area. There is a dining room, lounge with conservatory, kitchen and four bedrooms, one of which is a sleep-in room/office. The home is surrounded by a well maintained garden which service users can access safely. There are separate laundry and storage facilities. The home is situated close to the town centres of High Spen where a range of community facilities such as shops and public houses can be easily accessed. There are bus stops nearby which link with the main regional centres. The home also has its own transport. Shian DS0000007387.V309156.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day in September 2006 and was an unannounced key inspection. The inspection included information which had been provided by the manager in a questionnaire. Due to the complex needs of the service users comments cards had not been sent to them to complete, however, questionnaires were sent to each of their relatives. All three relatives completed and returned a questionnaire to the Commission before the inspection. Time was spent talking to the manager and staff and the service users were present throughout. Some time was spent looking at the home, including the lounge, dining room and garden. A sample of staff records were also looked at. The inspection focused on all three service users, all of who have with very different needs. This is known as “casetracking”, and this involved looking at what it was like, from their point of view, living at Shian. As the service users are not able to use speech to express their views this involved watching the staff’s care practices with them and checking that information obtained from discussion with staff and observation was accurately recorded in the care records. The weekly fees payable by service users is £62.35. The full weekly cost of care for 2006/2007 is £1897.80 What the service does well: The people living at Shian have complex needs and in order to involve them more in making choices and decisions the staff have made sure there is lots of information in their care plans about how they communicate. Care plans are good and the staff have worked hard to make sure that the information in them is up to date. There are lots of staff around so that the service users can take part in a variety of leisure activities. As well as things going on in the house such as “P.A.T. dog”, (which is a dog and their owner who regularly visit the service users), and aromatherapy, there are lots of trips out arranged for people. The home has its own transport, which is very good, as one service user, who doesn’t like to walk very far, enjoys long drives out instead. Shian DS0000007387.V309156.R01.S.doc Version 5.2 Page 6 If a service user is unwell the staff make sure they get to see their GP quickly and the staff always arrange for service users to attend other health care appointments regularly. The food is nice and lots of choices are available. The service users have lots of contact with their families. If their family is not able to visit them at Shian then the staff make sure the service user is able to visit them in their own home. Relatives said they knew how to complain and staff have had training so that they know what to do to stop people from being abused. The house is homely and clean and there is a lovely garden that the service users can use in warmer weather. The staff have had lots of training so that they can do their job well. As well as health and safety training this has included specialist training such as “conflict resolution” in order to help them meet the specific needs of the service users. As well as making sure the views of relatives and staff are obtained there are good quality assurance systems in place to make sure that high standards of care are provided. For example: the staff carry out weekly checks to make sure that everyone has been given their medicine at the right times. Relatives said : “the atmosphere in the home is always welcoming” and “Claire is doing an excellent job with the home and her staff”. What has improved since the last inspection? Lots of work has been done by staff so that risk assessments are kept up to date. This is important as it shows how the service users are helped to lead independent lifestyles. Two of the service users, for the first time in a number of years, have been supported by staff to enjoy a holiday. For one service user this was a short break in a country hotel, for the other service user a mini break in a caravan. More than half the staff now have an NVQ level 2 qualification in care, which is above the national minimum standard. All of the service users have been provided with a new bed. Shian DS0000007387.V309156.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Shian DS0000007387.V309156.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 Shian DS0000007387.V309156.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users needs are always assessed prior to admission in order to determine that their needs can be met in the home. EVIDENCE: Although there have been no new admissions to the service since the home first opened some years ago, there are clear admission policy and procedures in place. This includes obtaining an up-to-date care management assessment so that future prospective service users are assured that the service will be able to meet their needs. Recently the needs of all three service users have been re-assessed by a social worker to make sure that their needs continue to be met at Shian. Due to the complex needs of the service users the manager confirmed that the staff have been fully involved in this process as advocates on their behalf. Shian DS0000007387.V309156.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,&9 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The plans of care for individual service users continue to improve and give specific information about service users as individuals, which helps to provide a good quality of care. Service users are able to take risks and the staff continue to develop ways of communicating with the service users in order to help them make choices in their daily lives. This enables the service users to lead independent lifestyles. EVIDENCE: Care plans provide staff with clear guidance on the action they need to take to meet the service users assessed needs. They are written in such a way as to ensure that service users are given as much control as possible over the activities of daily living. For example: for one service user this means they are able to eat their meals independently, the care plan providing staff with guidance on how to enable them to achieve this goal. The level of detail in some of the care plans was excellent. For example: one care plan included the type of bubble bath a service user liked to use and this ensures that this service user receives personal care and support in the way that they prefer. Shian DS0000007387.V309156.R01.S.doc Version 5.2 Page 11 In order to address one service user’s needs, particularly in relation to her behaviour towards another service user, staff respond in a particular way to them. However, there were no written guidelines in place. This is important to ensure that staff adopt a consistent approach. Information on the service users method of communication is included in a picture care plan. This provides staff with good information and enables them to support the service user’s to make decisions and choices. During the inspection this was observed when a service user used non-verbal communication which staff understood to mean that they wanted a particular CD to be played. As demonstrated through the care plans service users are encouraged to be independent in all areas of their daily life, such as personal care tasks and taking part in activities inside and outside the home. All of these can involve taking a degree of risk. The manager assesses any hazards that may be involved in carrying out certain tasks, as well as identifying any benefits and pitfalls. If hazards are too great, choices may be restricted to promote safety for that person. Information about risks are recorded in the format of a risk assessment; this allows staff to give the correct amount of support to the person as well as reducing any further chances of hazard. Examples of risk assessments in place include going out for walks in the community, using the kitchen, lifting the kettle and going out of the door if it is left unlocked. None of the service users have an advocate. The manager confirmed that this is because there are a shortage of advocates in the area, however, she has ensured that all three service user names have been placed on the waiting list. Shian DS0000007387.V309156.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16&17 Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are supported to take part in a wide range of activities both inside and outside the home. Service users are assisted to maintain links with their families and to have a regular community presence. This will assist them to lead a full and enjoyable life. Service users are provided with a nutritious, varied diet which helps to promote their general health and well being. EVIDENCE: There is an activities timetable which shows what each service user will be doing each day. This includes activities indoors such as aromatherapy and “P.A.D. dog” to activities in the local community ranging from going for a walk to the local shop or in the country to trips to the local swimming baths. An enabler is employed to work in the home 3 days each week. The enabler is a person whose sole responsibility is to support the service users with leisure activities in the community. On the day of the inspection an enabler arrived and with the help of care staff supported two service users to enjoy a trip to a Shian DS0000007387.V309156.R01.S.doc Version 5.2 Page 13 multi-sensory room based at Prudhoe Hospital. The enablers complete an annual review of the activities they have supported the service users with. This information is used to help ensure future activities provided are planned around the service users likes and preferences. During lunch the staff talked of forthcoming shows and their plans to ensure that there were plenty of activities booked for the service users over the Christmas period. Two of the service users, who, due to their complex needs, have not had a holiday away from their home in a number of years. However, it was excellent to note that with careful planning and appropriate staff support, in the last year they have both experienced a holiday. The staff and manager said that this was such a positive experience for each of the service users that this is now to be a regular occurrence in their lives. Although none of the relatives were visiting on the day of the inspection information received from them confirmed that they are able to visit their family member at any time and are always made to feel welcome by the staff. The staff said that one service user had recently been supported by them to visit their relative in their home and the staff said “Claire likes the service users to keep in touch with their families”. It was evident that the routines of the home are flexible and reflect the service users choices. Staff said that in the morning one service user likes to get up later than the others and have a shower, and this is an important part of their daily routine, which is respected by the staff. Mealtimes are also very flexible and times of meals depend on the routines and activities that service users are attending. The Inspector sat and chatted with service users and staff over lunch, the experience of which was similar to that of a large family. The meal had been prepared by staff, as due to the complex needs of the service users, they are not able to help in this area. One service user, however, likes to sit and watch staff whilst they are in the kitchen and a small chair has been placed in this area so that they can do this in comfort. Specialist aids have been provided so that service users can drink independently and throughout the meal the staff encouraged the service users to eat independently. Menus are planned and decided based upon the service users likes and dislikes, which is recorded in their care plans. A picture menu has been developed as a communication aid to involve the service users in this process. Shian DS0000007387.V309156.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19&20 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users receive the support they need from staff to ensure that their personal, physical and emotional health needs are met. The service users are protected by the homes medication policies, procedures and practises. EVIDENCE: The care plans provide clear guidance to staff on the service users preferences on how their personal care needs are to be met. The areas covered within the care plans include personal care, self-image and eating a meal. The care plans are all different and the content reflects the personal care needs of each service user. Care plans examined confirmed that the service users have regular access to their GP and other medical professionals such as the District Nurse. Discussion with the manager concluded that she has contacted the Behavioural Nurse in order to assist the staff with developing a behavioural care plan for one service user. She has also made a referral for a speech therapist to help develop the service users methods of communication. Shian DS0000007387.V309156.R01.S.doc Version 5.2 Page 15 A monthly review of the service users needs is carried out within which any changes in the service users health care are closely monitored. Medication records examined confirmed that medication is administered to service users appropriately. Systems are in place for ordering and the safe disposal of medication. An audit of the medication held in the home was checked and correct and corresponded to the medication administration records, which are held on one file and contain good detailed information. Medicines are stored safely and securely and follow the Royal Pharmaceutical guidelines. No controlled drugs are held within the home at this time. Shian DS0000007387.V309156.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22&23 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Appropriate policies and procedures are in place, supported by staff training, which ensure that service users are protected from abuse and neglect. Whilst service users communication skills are very limited, arrangements are in place through the complaints process to promote their safety and offer protection. However, the complaints procedure does not inform the relatives and service users that they can complain to the Commission for Social Care Inspection, therefore their rights are not fully promoted in this area. EVIDENCE: There is a complaints procedure available to the service users in plain language and large print. However, an examination of this document confirmed that it does not advise the complainant that they can contact the Commission for Social Care Inspection at any stage should they wish to do so. This is a legal requirement, raised during the last inspection, which must be addressed. Relatives said in the questionnaires received that they knew how to make a complaint but had never felt it necessary to do so. Staff said that they had had training in relation to the protection of vulnerable adults. There is also written information available to staff, called “don’t delay” advising them of their duty of care to report bad practise or any suspicion of abuse. Shian DS0000007387.V309156.R01.S.doc Version 5.2 Page 17 Policies, procedures and staff practices also ensure the financial protection of service users. Records showed that for all transactions made on behalf of the service users, two staff signatures as well as receipts are obtained. Regular internal and external audits of the service user’s personal money are carried out and relatives are always consulted about any major purchases, such as bedroom furniture. All three service users have their own personal bank account. Shian DS0000007387.V309156.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24&30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The environment is homely, comfortable and clean providing the service users with a safe place to live. However, some of the communal carpets require attention in order to provide a well maintained environment promoting a positive image of the service users. EVIDENCE: The building throughout was found to be clean with no unpleasant odours. There is a communal lounge and a conservatory area, which leads from the lounge into the garden. There is also a separate dining area and these are bright, airy comfortable places in which the service users can engage in activities of their choice. Overall the building was well maintained, however, the carpets in the corridor and lounge are old and shabby in appearance. Discussion with the manager confirmed that the communal carpets have not been replaced since the home opened, approximately ten years ago, and despite her efforts to address this by raising this with the organisation, she was unable to confirm whether or not these are to be replaced. Shian DS0000007387.V309156.R01.S.doc Version 5.2 Page 19 Since the last inspection new beds have been purchased for each service user. The staff are responsible for cleaning but as far as possible they encourage the service users to help them with this. The staff help and support the service users to keep their bedrooms clean and this is recorded in the activities timetable. Detailed policies and procedures are available in relation to infection control and discussion with the manager and staff confirmed that they have all had training in relation to this as part of their induction training. Protective gloves and aprons are available for staff to use. Shian DS0000007387.V309156.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,&35 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users benefit from skilled, experienced staff and the good staffing levels ensure that the service users needs are readily met. Staff records are not held within the home and as such it was not possible to confirm that the service users are supported and protected by the home’s recruitment practices. EVIDENCE: There are always two but more often than not three staff on duty during the day. In addition to this as previously mentioned there is an enabler on duty three days a week. There is always one person who sleeps in and a waking night staff. These staffing levels are major contributing factors in assisting service users to lead rich and varied lifestyles. The organisation provides staff with opportunities to go on a wide range of training. In addition to mandatory training such as food hygiene and fire safety this has included training in specialist topics such as “conflict and resolution”. Some of the staff have also completed training in relation to the Disability Discrimination Act. Shian DS0000007387.V309156.R01.S.doc Version 5.2 Page 21 There are only 5 of the 14 staff left to complete the NVQ level 2 training in care, which exceeds the minimum standard of 50 . Staff said that the training is “good” and that the NVQ training had really helped them to question and improve their care practice. Staff recruitment records are kept centrally so were not seen. However, the manager assured the inspector that the personnel staff make sure that CRB checks are completed, references obtained and full employment histories taken. There has been no turn over in staff in the last year which is important in terms of promoting continuity of care. Shian DS0000007387.V309156.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40&42 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Overall management systems are effective and ensure that the health, safety and welfare of service users are promoted. However, staff, service users and their relatives are not provided with information advising them of how the organisation intends to meet the diverse needs of the service users and therefore anti-discriminatory practice may not be challenged. EVIDENCE: The manager uses supervision systems to make sure staff constantly reflect upon their practice and support service users to reach their potential. She critically looks at practices in the home and tries to find ways to make sure staff are always working in line with current good practice. For two of the service users, as previously mentioned in the report, this has meant that they have had the opportunity of going on holiday. She has successfully gained the NVQ level 4 in care and the Certificate in Learning disabilities. Shian DS0000007387.V309156.R01.S.doc Version 5.2 Page 23 The organisation has a comprehensive internal quality assurance system in place, “Total Quality Management”. Currently staff are monitoring maintenance reporting, medication records and fire panel checks to make sure that the required standards are maintained. In addition to the internal checks the organisation use relative and staff questionnaires to find out their views of the service provided. An annual report is published each year based on the findings of surveys and internal auditing and highlights areas of improvement for the following year. Appropriate records are held in relation to accidents. The fire log book examined confirmed that fire alarms are tested regularly and fire equipment and emergency lighting checks are carried out as recommended by the fire authority. Although there are many policies and procedures in place, which are regularly reviewed, the home does not have a policy on equality and diversity. During the inspection there were no health and safety risks noted. Shian DS0000007387.V309156.R01.S.doc Version 5.2 Page 24 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 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 4 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 3 X 2 X 3 x Shian DS0000007387.V309156.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement Care plans must be developed to provide guidelines for staff on the action they should take in relation to one service user’s behaviour. The complaints procedure must include the name, address and telephone number of the Commission for Social Care Inspection and inform the complainant that they can contact the Commission for Social Care Inspection at any stage. (Timescale not met 31/05/06). The “shabby” carpets in the lounge and corridor must be addressed. Timescale for action 31/12/06 2. YA22 22(7) 31/12/06 3. YA24 23(2)(b) 31/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Shian Refer to Good Practice Recommendations DS0000007387.V309156.R01.S.doc Version 5.2 Page 26 1. Standard YA40 The organisation should develop a policy and procedure on equality and diversity. Shian DS0000007387.V309156.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Shian DS0000007387.V309156.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. 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!