Inspection on 26/11/07 for Shian

This inspection was carried out on 26th November 2007.

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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shian 18/11/08

Shian 14/09/06

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 Mrs Elsie Allnutt Key Unannounced Inspection 26th November 2007 10:00 Shian DS0000007387.V349818.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.V349818.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.V349818.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 549 534 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.V349818.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th September 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. The home has developed a Service User Guide so service users and other interested people are informed about what this service provides. Shian DS0000007387.V349818.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took 6 hours over one day in November 2007. As the manager was unavailable on the day of the site visit, a telephone discussion with her took place on the following day. The judgements made are based on the evidence available to the inspector during the inspection and during the discussion with the manager. In addition to this: • Information received in the Annual Quality Assurance Assessment (AQAA) completed by the manager. • Discussions with service users and staff. • A tour of the building • Examination of service users’ and staffs’ records, were also taken into consideration. As all of the service users do not have effective verbal communication, their satisfaction with the service was interpreted through the observations of body language, interaction with staff, discussions with staff and the examination of records. All service users were happy in their environment and with the care received from staff. A lot of the time was spent interacting with service users including enjoying a cup of coffee on arrival and later a cup of tea with the service users and staff around the dining table. A light lunch was also provided In the absence of the manager the person in charge of the home competently dealt with the inspection. 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 about their lives a lot of information about how each person communicates is written in their care plans. Care plans are good and the staff have worked hard to make sure that the information in them is easy to read and 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. Shian DS0000007387.V349818.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 good 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. The home has information about how to complain and this is also described in pictures so that service users might be able to understand the information more easily. Staff have had training so that they know what to do to stop people from being harmed in any way. The house is clean and tidy and there is a 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. This means that service users are supported and cared for in the right way. There are good systems in place that makes sure good standards in the home are kept and that the views of service users, their relatives and staff are listened to. This means that the service received by the service users is good and in their best interests. What has improved since the last inspection? What they could do better: Although there is a complaints procedure in place, more information must be included in it so that people know how to get in touch with the Commission for Social Care Inspection (CSCI) if they want discuss any issues about their complaint. The carpets in the corridor and dining room are old and shabby and badly stained in places. The organisation must sort this out so that the service users live in a home that is attractive, well looked after and is pleasant to be in. The carpets are also starting to move and make ripples and in one area the carpet is coming away from the join. This means that it could be dangerous Shian DS0000007387.V349818.R01.S.doc Version 5.2 Page 7 for service users when they are moving around as they could trip and fall. To avoid this from happening the carpets must be replaced or repaired. So that service users can bathe safely and comfortably, the special bath and the shower facility must be repaired. So that the health and safety of service users and staff are not put at risk, the repairs needed in the shared areas of the home, including the kitchen and conservatory must be carried out. The requirements made in the last inspection report that have not been met must, as a matter of urgency be addressed. The manager must send off an application to the CSCI so that her fitness to manage this services can be assessed. This will assure the service users and their relatives that the home is run in the correct way. 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. Shian DS0000007387.V349818.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.V349818.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good multidisciplinary preadmission assessments demonstrate service users’ needs and aspirations and assist the home to make an informed judgement as to whether they can meet these. EVIDENCE: This home has clear procedures in place regarding anyone moving in. The home opened in 1996 when all service users, now living here, moved in. There have been no new admissions since. However prior to any new person moving into the home the procedures dictate that a full assessment of need is received from the referring agency, with a current care plan. With this information and an assessment carried out by the service, the home can then make an accurate judgement as to whether they can meet the referred person’s needs. Over the past year the needs of all service users have been re-assessed by a social worker and other healthcare specialists to make sure that their needs can continue to be met at this home. Shian DS0000007387.V349818.R01.S.doc Version 5.2 Page 10 Due to the complex needs of the service users the staff were fully involved in this process as advocates on their behalf. Staff addressed the individual needs of the service users with understanding and competence. Shian DS0000007387.V349818.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans that guide staff to appropriately support service users’ care needs and also enable them to support service users to make choices about their lives, are in place and are an outcome of ongoing assessment and while service users are supported to take risks safely, they are also supported to develop their independence. EVIDENCE: There is a care plan in place, that is person centred led, for each service user living at this home. The information recorded in them is in very good detail, up to date and clearly guides staff to effectively address the individual service users’ personal, social and emotional care needs. As all service users who live at this home have complex needs and are not able to direct their own care verbally. Therefore it is important that staff have enough information to address their many individual needs. Shian DS0000007387.V349818.R01.S.doc Version 5.2 Page 12 A eating plan for one person clearly guides staff to prepare and serve food in a way that addresses the individual’s needs, and guidelines in the risk management plan, show staff how to support the person and to reduce the identified risk related to the possibility of weight loss and of choking. Care plans are also in place in relation to maintaining individual service users’ self esteem. Particular guidelines are in place for staff to follow regarding how individuals prefer to dress, with emphasis on promoting the person in a positive image and also regarding the toiletries they like to use. This not only reflects the service user’s choices and preferences, it also promotes their right to being supported in a dignified and respectful way. Details regarding individual service users’ methods of communication are a significant piece of information that is included in an illustrated care plan. This provides staff with good information about the person and enables them to support the service user to make decisions and choices. Staff interact with service users in a way that reflects this knowledge. Service users’ needs are regularly reviewed and care plans are adapted to reflect these. Although the care plans are reviewed every six months they are monitored monthly. The most recent reviews took place November 2007. Shian DS0000007387.V349818.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported to live fulfilling lifestyles both in their own home, the local community and with their families and friends. Whilst doing this, the service supports service users’ rights and promotes their independence. Meals are healthy, nutritious and attractive, and are prepared in order to meet the individual dietary needs of each service user. EVIDENCE: All of the service users have individual weekly activity programmes that are evident in a “diary”, that is part of their care plan. These vary according to individual preferences but confirm well-organised and active lifestyles. Some activities are mainly centred in the community, while others are based in the home. Shian DS0000007387.V349818.R01.S.doc Version 5.2 Page 14 The home is well run and organised and promotes respect for service users and their rights to privacy. Staff care practices reflect these. Service users’ rooms are respected as their private space and service users move around the home with confidence, demonstrating ownership of their environment. Activities indoors include aromatherapy and the use of sensory equipment and activities in the local community range from going for walks in the country, visiting places of interest, for example a recent trip was to a deer park, to trips to the local swimming baths and bicycle riding using adapted cycles. An enabler is employed to work in the home 3 days each week. This is someone whose sole responsibility is to support the service users with leisure activities in the community. The enabler works closely with the other members of the staff team and maintains clear detailed records of the activities experienced, noting what has been successful and how the individual has responded to it. This information is extremely valuable and helps to build up a picture of the person as an individual and can be used to support service users when making decisions and choices about their lives. Staff supported service users to chat about holidays taken this year. Two service users enjoyed individual holidays to different venues reflecting their personal needs and preferences, and events planned for the build up to Christmas were also discussed. This chat took place around the dining table during a break for a cup of coffee and tea. Mealtimes are very flexible and times of meals depend on the routines and activities that service users are attending. Menus that are based on nutritious food, are planned and decided based upon the service users likes and dislikes, which are 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.V349818.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a 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 and that they are protected by the homes medication policies, procedures and practises. EVIDENCE: Service users are supported to register and attend healthcare practices in the local community. Visits to the GP, dentists, opticians and other healthcare professionals are recorded in individual care files with the outcome of the visit. For example one care file recorded visits to a Women’s Health Clinic and the outcomes were recorded. Staff work closely with healthcare officials involved in the lives of individual service users and healthcare needs are clearly recorded in the care files and developed as a care plan if needed. Shian DS0000007387.V349818.R01.S.doc Version 5.2 Page 16 Any health or behaviour changes that are observed by staff are clearly recorded in the daily notes and if needed action is taken to gain specialist healthcare advice. The guidance given is then recorded in the care plan. Advice has recently been received in relation to challenging behaviours and guidelines are now in place for staff to follow in relation to this. A Speech Therapist has given Intensive Interaction advice to staff in relation to one person’s communication needs. Although staff are well trained regarding service users’ needs, they are also aware of their own limitations and state that they find this sort of interaction from specialists very supportive. Care reviews identify current healthcare needs and how these are to be addressed, for example for one person the issues around weight loss and eating habits were discussed and as a result a care plan was put in place to support the service user and to address the issues raised. Staff receive training in the administration of medication and their knowledge and the way medication is stored and administered reflects this. Individual care plans are in place with guidelines for staff to follow regarding how individual medication is administered to service users. This ensures that their complex needs are addressed during an important process. . Shian DS0000007387.V349818.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to help protect service users from abuse and to seriously address complaints and concerns about the service. EVIDENCE: The home has a comprehensive complaints procedure that is in picture format in an attempt to make it more accessible to the service users. Staff receive 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. Policies, procedures and staff practices ensure the financial protection of service users. Records demonstrate all transactions made on behalf of the service users and 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 consulted about any major purchases, such as bedroom furniture. All service users have their own personal bank account. Shian DS0000007387.V349818.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,27,28,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment is clean and tidy, however the lack of an ongoing maintenance programme means that the home is now beginning to fail to promote a positive image and potentially compromise the safety of the people who live and work there. EVIDENCE: The home is kept clean and tidy, however there are areas that are in need of redecorating, refurbishing and being made safe. The décor in the lounge is bright and clean but the paint on the walls in the dining room is damaged and the décor generally is showing signs of wear and tear and is in need of attention. Shian DS0000007387.V349818.R01.S.doc Version 5.2 Page 19 The carpet in the dining room is stained and has ripples appearing in many areas, which present a tripping hazard particularly to people who maybe are unaware of them and who have mobility problems. There is also a hazard at the doorway of the dining room and hallway where the carpets meet; here the dining room carpet has come away from the join and is beginning to fray and again presents a danger of tripping, particularly to service users. The hallway carpet has heavy stains that are unsightly and of concern knowing that a service user can use their hands and knees to get around. These issues were brought to the attention of the staff and the team leader who agreed to address them. The kitchen is clean and well organised, however due to the age of the fitted units some are now not functioning properly, draws are difficult to open and do not run smoothly on their runners. This can prove difficult for staff to safely access kitchen utensils. A specialised bath has been installed in one of the bathrooms, designed to meet the particular needs of one service user, with the aim that they can use the bath comfortably and safely. This bath is currently broken and has not been in use for several months. Service users therefore are denied a choice of bathing facilities and currently use the shower in the second bathroom. However due to damage to the flooring in the shower area, dirty water is returning back into the bathroom. Plans are in place for this to be addressed directly. The conservatory has been fitted with sensory lights that service users particularly enjoy and respond to in the evening when the effect is clearer against the darkness from outside. Unfortunately the use of this area is restricted due to a leak in the roof that is causing water to enter the conservatory. Plans are in place for this to be addressed directly. Shian DS0000007387.V349818.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. JUDGEMENT – we looked at outcomes for the following standard(s): 33,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Robust recruitment & selection procedures and regular training opportunities ensure that service users are appropriately supported and protected by a competent and qualified staff team. EVIDENCE: The good staffing resources at this home are instrumental in supporting service users to lead rich and varied lifestyles. The home aims to have three staff on duty each day, however this number may fall to two at times of staff sickness. In addition to this basic number, an additional member of staff, in the role of an enabler, is employed at the home three days a week. This person also coordinates the varied activity programmes for the individual service users. The good care practice demonstrated by staff reflects the comprehensive training programme in place. As well as keeping mandatory training up to date, staff attend other training relevant to their role. Staff work towards NVQ and have attended training regarding challenging behaviour, the Disability Discrimination Act and Equality and Diversity. Shian DS0000007387.V349818.R01.S.doc Version 5.2 Page 21 All of the staff who work at this home have worked there for many years and have gained an abundance of important information and understanding regarding the needs and the personalities of the individual service users. Staff and service users interact in a positive way that reflects positive relationships. No new staff have been recruited to this home over the past twelve months, however comprehensive recruitment procedures, that are managed from the Trust’s central office, are in place. CSCI have an agreement with Northgate and Prudhoe Trust that any staff records that need to be examined can be accessed either as a prearrangement or without notice. Shian DS0000007387.V349818.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the overall management systems in the home are effective, there are health and safety issues that could put service users at risk of harm. EVIDENCE: The manager who is not yet registered with the CSCI was transferred to this home in July this year as Acting Team Leader. She has worked for many years in similar services and has gained NVQ4 in Management. A senior member of staff has recently been appointed to support the manager in her role. The organisation has a comprehensive internal quality assurance system in place, “Total Quality Management”. Currently staff monitor maintenance Shian DS0000007387.V349818.R01.S.doc Version 5.2 Page 23 reporting, medication records and fire panel checks to make sure that the required standards are maintained. However it is noted that two requirements made in the previous inspection report have failed to be addressed. These must be addressed as a matter of urgency. In addition to the internal checks, the organisation uses relative and staff questionnaires to find out their views on 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 and fire safety. Fire alarms are tested regularly and fire equipment and emergency lighting checks are carried out as recommended by the fire authority. Although staff work reflecting good health and safety practices the following health and safety issues were brought to the attention of the manager and service manager and must be addressed: • • • • • • • The hazard caused by ripples in the dining room carpet. The loose join in the carpets between the dining room and the hallway. The heavy stains in the hallway carpet. The kitchen units that are not functioning properly. The adapted bath that is broken. The damaged floor in the bathroom that is allowing dirty water to flow back into the bathroom. The leak in the conservatory roof. Shian DS0000007387.V349818.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 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 2 28 2 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 2 3 3 X X 2 X Shian DS0000007387.V349818.R01.S.doc Version 5.2 Page 25 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA24 Regulation 23(2)(b) Requirement Timescale for action 31/12/07 2 YA24 3 YA27 4 YA28 5 YA37 The registered person must ensure that the shabby carpets in the lounge and corridor must be addressed. Timescale of 31/12/06 not met. 13(4)(a)(c) The registered person must ensure that the areas identified in the home as needing attention are addressed so that the health and safety of service users and staff are not compromised. 13(4)(a)(c) The registered person must ensure that: the broken adapted bath is repaired, and the damage to the shower room floor that is allowing dirty water to flow back into the bathroom is repaired. 13(4)(a)(c) The registered person must ensure that the repairs needed to the shared areas of the home, including the kitchen are carried out. 9 The manager must make an application to the CSCI to be considered as a fit person to be the Registered Manager for the home. DS0000007387.V349818.R01.S.doc 14/12/07 14/12/07 14/12/07 31/12/07 Shian Version 5.2 Page 26 6 YA37 12(1) 7 YA42 13(4)(c) The registered person must ensure that any requirement made by the CSCI in their report is addressed and completed in the required timescale. The following health and safety issues that were brought to the attention of the manager must be addressed: • The hazard caused by ripples in the dining room carpet. • The loose join in the carpets between the dining room and the hallway. • The heavy stains in the hallway carpet. • The kitchen units that are not functioning properly. • The adapted bath that is broken. • The damaged floor in the bathroom that is allowing dirty water to flow back into the bathroom. • The leak in the conservatory roof. 14/12/07 14/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA40 Good Practice Recommendations The organisation should develop a policy and procedure on equality and diversity. Shian DS0000007387.V349818.R01.S.doc Version 5.2 Page 27 ` Commission for Social Care Inspection South Shields Area Office 4th Floor 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 Shian DS0000007387.V349818.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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