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Inspection on 25/06/08 for St Barbara`s Walk (35)

Also see our care home review for St Barbara`s Walk (35) for more information

This inspection was carried out on 25th June 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

This service provides accommodation of a good standard. It is well maintained and clean. The friendly relationship between service users and staff creates a warm and welcoming atmosphere in the home. The staff, some who have worked at the home for several years, have a good understanding of their roles and work well as a team. They have very strong principles centred on those in the government`s White Paper Valuing People and they are enthusiastic about their work. This is reflected the delivery of good quality care and the empowerment of the service users.The home welcomes visitors and positively encourages the relationships between family, friends and service users to be maintained. Service users spoke positively about visiting family members. Staff are trained well so that they have the necessary skills to support the service users at the level they need. The manager is well experienced and knows how to run the service in the best interests of the people who live there, this means that service users are consulted about the way they wish to live and listened to when they have concerns. A variety of activities are offered and service users are encouraged to maintain their own interests. Service users live individual and very interesting lifestyles. Service users are also supported to develop their confidence and the way they deal with difficult situations. This means that service users can mix with other people in the community confidently. All residents have some form of meaningful daytime occupation, for example real work, college, volunteer positions, local authority or independent sector day care away from the home. The home is now working with `Work Able Solutions` to seek real/supported employment opportunities. The home has access to three fully maintained ordinary vehicles that are used to get service users out and about.

What has improved since the last inspection?

Service users continue to be supported at a level that their needs dictate. A new website has been developed and as a result information about the service is now easily available to a wider audience via IT systems.

What the care home could do better:

The care plans should be monitored monthly and this should be recorded in the identified place in the care plan document. The home should develop a quality monitoring system that demonstrates the service is developed in the best interests of the service users.

CARE HOME ADULTS 18-65 St Barbara`s Walk (35) 35 St Barbara`s Walk Newton Aycliffe Durham DL5 4AN Lead Inspector Mrs Elsie Allnutt Key Unannounced Inspection 25th June 2008 09:30 St Barbara`s Walk (35) DS0000007566.V366819.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 St Barbara`s Walk (35) DS0000007566.V366819.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. St Barbara`s Walk (35) DS0000007566.V366819.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Barbara`s Walk (35) Address 35 St Barbara`s Walk Newton Aycliffe Durham DL5 4AN 01325 319083 01325 314621 steapuk@aol.com 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) Mr Ian Thomas Patterson Mr Stephen Andrew Patterson Care Home 3 Category(ies) of Learning disability (3) registration, with number of places St Barbara`s Walk (35) DS0000007566.V366819.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th July 2006 Brief Description of the Service: St Barbara’s Walk is a Residential Care Home providing residential care services for up to 3 adults with learning disabilities. St Barbara’s Walk is part of a small group of homes owned by the Registered Provider Mr Ian Patterson that is located in a residential part of Newton Aycliffe and within walking distance of the town centre and its amenities. It is a small terraced house providing suitable living accommodation for its residents. The accommodation at St Barbaras Walk comprises of 3 single bedrooms, a communal bathroom, a kitchenette and a lounge/ dining area. There is a small- enclosed garden area to the front and the rear of the house and there are ample parking spaces at the rear of the house and at the end of the terrace. The home has developed a Service User Guide that is accessible to service users. St Barbara`s Walk (35) DS0000007566.V366819.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. Before the visit: We looked at: • Information we have received since the last visit. • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on 25th June 2008. During the visits we: • • • • • • Talked with people who use the service, staff, the manager & visitors. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit. We told the manager what we found. What the service does well: This service provides accommodation of a good standard. It is well maintained and clean. The friendly relationship between service users and staff creates a warm and welcoming atmosphere in the home. The staff, some who have worked at the home for several years, have a good understanding of their roles and work well as a team. They have very strong principles centred on those in the government’s White Paper Valuing People and they are enthusiastic about their work. This is reflected the delivery of good quality care and the empowerment of the service users. St Barbara`s Walk (35) DS0000007566.V366819.R01.S.doc Version 5.2 Page 6 The home welcomes visitors and positively encourages the relationships between family, friends and service users to be maintained. Service users spoke positively about visiting family members. Staff are trained well so that they have the necessary skills to support the service users at the level they need. The manager is well experienced and knows how to run the service in the best interests of the people who live there, this means that service users are consulted about the way they wish to live and listened to when they have concerns. A variety of activities are offered and service users are encouraged to maintain their own interests. Service users live individual and very interesting lifestyles. Service users are also supported to develop their confidence and the way they deal with difficult situations. This means that service users can mix with other people in the community confidently. All residents have some form of meaningful daytime occupation, for example real work, college, volunteer positions, local authority or independent sector day care away from the home. The home is now working with ‘Work Able Solutions’ to seek real/supported employment opportunities. The home has access to three fully maintained ordinary vehicles that are used to get service users out and about. 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. The summary of this inspection report can be made available in other formats on request. St Barbara`s Walk (35) DS0000007566.V366819.R01.S.doc Version 5.2 Page 7 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 St Barbara`s Walk (35) DS0000007566.V366819.R01.S.doc Version 5.2 Page 8 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): 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good processes are in place that informs service users about the home and the service about prospective service users’ needs. This means that people interested in using the service can make informed choices and that the service has the appropriate information to make a decision that they can meet the referred person’s needs. EVIDENCE: The home has developed a Statement of Purpose and Service User Guide that is in a format that service users can understand. In addition to this the service has recently developed a website that gives extensive information about the service. When asked if they received enough information about the home one service user said, “I was given a booklet that told me everything about the home and I was asked if I wanted to live here.” When a referral for care is received by the home a full assessment of need is requested from the referring agency. Information about the home is given to St Barbara`s Walk (35) DS0000007566.V366819.R01.S.doc Version 5.2 Page 9 the interested person who is also invited to visit the home to meet the other people who live and work there. The pace of this process is determined by the individual’s needs so that an informed decision to move in can be made. When a decision has been made there is a three-month probationary period during which time the home carries out an assessment of need during which time as much information about the person as possible is collected. From the information gathered during the initial assessment process a comprehensive care plan is developed and any identified risks are addressed and plans are put in place so that the risk is reduced. This home does not receive emergency admissions. St Barbara`s Walk (35) DS0000007566.V366819.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 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 are the outcome of ongoing assessment, guide staff to appropriately support service users’ care needs, promote their independence by safely addressing risks and enable staff to support service users to make choices about their lives. EVIDENCE: There is a care plan in place for each service user living at this home. The information recorded in them is current and clearly guides staff to effectively address the individual service users’ personal, social and emotional care needs. The care plans demonstrate the 24-hour activity routine for each service user and the support needed within this. In addition to this lists of the individual’s likes and dislikes and strengths and needs are included. These indicate the level of support needed from the care staff, the service users’ level of independence and their preferences. St Barbara`s Walk (35) DS0000007566.V366819.R01.S.doc Version 5.2 Page 11 The records clearly show that service users are empowered by being encouraged and supported to make their own choices about their lives. The service has assisted all service users to develop their independence and they are now able to manage their lives, as they prefer. The care plans reflect this. All of the people living at this home are independent with personal tasks although prompts from staff are needed regarding some areas, for example someone may need to be prompted about bathing or washing their clothes. The level of support needed is clearly recorded and service users confirmed that this is the case. The home aims to monitor care plans monthly and individual annual reviews take place. The outcomes of the annual reviews are recorded in the care files and the daily notes are clearly recorded in good detail. The home now presents service users’ risk assessments as part of the Social Care and Health’s annual review process and the assessments are reviewed, agreed and shared. However although there is a place to record monthly monitoring in the care plan document, these are not consistently recorded. This could mean that changes in an individual’s needs are not recorded and the care plan is not brought up to date. However staff confirmed that they regularly discuss any changes in service users’ needs. Service users were able to discuss the content of their care plan and how any risks to their safety are addressed. Clear risk strategy plans assist service users’ to promote their aspirations, decision making and independence safely. These are the outcome of risk assessments carried out regarding: service users being in the house alone, the self-administration of medication and service users being independently out in the community. St Barbara`s Walk (35) DS0000007566.V366819.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living at this home are empowered to live lifestyles that are individual and that reflect their personal preferences, culture and values, while at the same time they are supported to maintain relationships with family and friends of their choice. Meals are healthy and nutritious and prepared to meet the individual dietary needs and preference of each service user. EVIDENCE: All of the service users have individual weekly activity programmes that are recorded in their care plan. These are flexible but act as a structure to the individual’s week. They vary according to individual preferences but confirm well-organised and active lifestyles. Some activities are centred in the St Barbara`s Walk (35) DS0000007566.V366819.R01.S.doc Version 5.2 Page 13 community while others are based in the home depending on the needs and preferences of the service user. The home is run and organised to promote the recognition of respect, privacy and the rights of service users. The staff work to reflect this. Service users’ rooms are respected as their private space and service users move around the home with confidence, demonstrating ownership of their surroundings. Comments made by service users include, “I have my own key and I can come and go as I please. I please myself what I do but I let staff know where I am” “I let staff know where I am or I phone them on my mobile.” Service users have attended courses on assertiveness, stress control and conflict resolution. All have had a positive impact on their personal development and the promotion of their independence. The risks involved in promoting and supporting such independence have been addressed and risk strategy plans have been put in place. Each service user has a mobile phone with preset numbers of certain people who they can contact if needed. The care plans record the daily routines of the individual service users. Service users get up at their preferred time, use the areas of the home that they choose and move around as they wish. Care plans reflect the support service users need to carry out daily domestic tasks. For example one care plan said that, “ X needs assistance with sorting washing into washing machine into appropriate loads.” One service user commented, “Staff help us with the housework.” Service users openly discussed the variety of activities they take part in. This varies from doing paid work, working in an allotment, carrying out voluntary work for a local charity and attending college courses. In addition to this service users enjoy visiting Newcastle and local areas to do their shopping, visit pubs and entertainment venues. One service user has a full gym membership at a local leisure centre. Durham County Council now employs two service users as service user representatives in local parliament meetings where they help to make decisions for people with learning disabilities. One service user returned from such a meeting looking very smart and proud during the inspection process. The different holidays that are taken were also discussed. Each service user goes on 2 holidays each year, one fully paid by the organisation to Keswick St Barbara`s Walk (35) DS0000007566.V366819.R01.S.doc Version 5.2 Page 14 where they use the outdoor facilities of the Calvert Trust and one abroad, this year they plan to visit Lanzarote. Other plans in place include a visit to the motor show in London. The care files include details of employment contacts, volunteer centres and family and friends birthdays. Service users are encouraged and supported to keep regular contact with family and friends. One relative said, “There is a telephone for X to use or they can use their mobile to phone home and X comes home regularly.” Other relatives confirmed that the home supports service users to always keep in touch. Meals are determined by the service users choices and any allergies to food and individual service uses preferences are recorded in the care plans. Menus are regularly reviewed and agreed by service users and mealtimes are flexible to reflect individual routines and activities. Fresh produce including meat and fresh fruit and vegetables are delivered to the house. Service users confirmed that they receive good food that they enjoy. Some service users have undertaken accredited training and achieved foundation certificates in food hygiene. St Barbara`s Walk (35) DS0000007566.V366819.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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ personal and healthcare needs are met in a flexible but consistent manner, reflecting a healthy lifestyle and the medication arrangements are appropriate to the needs of service users. EVIDENCE: Service users are supported to register and attend healthcare practices in the local community. Visits to the GP, dentist’s, opticians and other healthcare professionals are recorded in individual care files, with the outcome of the visit. The home identifies and facilitates access to a whole range of additional health resources, i.e. dietician, continence advisor, epilepsy nurse, asthma nurse, neurologist, psychiatrist, audiologist and specialist dental/anxiety clinics. All necessary support is provided to attend outpatient/health appointments and the wishes of those service users who are able and wish to attend appointments on their own is respected. St Barbara`s Walk (35) DS0000007566.V366819.R01.S.doc Version 5.2 Page 16 The home works in partnership with service users’, families, friends, advocates and relevant professionals and they welcome assistance from family and friends to support service users with healthcare appointments and consultations. One relative said, “The home keeps me informed when X is feeling ill or when they have to go to the doctors and they kept us up to date when X had to go into hospital.” The people who live at this home generally enjoy good health, however when service users have medical problems like epilepsy risk strategy plans are put in place to guide staff in relation to the support needed. All staff have attended training in relation to epilepsy. In addition to this the home has worked with the epilepsy specialist nurse to ensure that those service users who require recovery medication for epilepsy have RISK MAPS (a care plan/risk assessment signed by resident, family, GP, nurse, consultant). This ensures consent and correct administration of the prescription. Staff support service users to live healthy lifestyles and they have supported service users to lose weight by eating healthily and to give up smoking. One service user makes their own appointments with the district nurse to have their blood pressure checks. The home has now more people safely self-medicating and less people actually taking prescribed medication. This is the result of working with the local GP’s and reviewing service users’ health needs. Appropriate risk management plans are in place for service users who selfmedicate. The home has an efficient medication policy supported by procedures and practice guidance, which staff understand and follow. Medication records are fully completed, contain required entries and are signed by appropriate staff. All staff have completed training regarding the safe administration of medication and the manager monitors compliance with the home’s procedures. St Barbara`s Walk (35) DS0000007566.V366819.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 and 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 that helps to 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. Service users and their relatives stated that they were generally very happy with the service delivered but if at any time they were not happy about something they knew what action to take. They were confident that staff would listen to them. One service user said that often things that they are unhappy about are discussed at the resident’s meeting and sometimes with a member of staff. Another service user said, “I know I can talk to staff and I can write in the book.” (The “book” referred to is The Complaints Book). The manager confirmed that concerns about the service delivered are taken seriously and used to improve the service delivered. As a result of a complaint being written in the book or brought to their attention the quality of pack lunches have now improved, a football shirt damaged in the wash has been replaced and the fruit order has been increased so more is available. St Barbara`s Walk (35) DS0000007566.V366819.R01.S.doc Version 5.2 Page 18 Staff have received training regarding the local authority’s Safeguarding Adults procedures and staff could state what action they would take if a safeguarding issue was reported to them. A copy of these procedures is kept in the home. Staff confirmed that they have received training in relation to Verbal and Physical Aggression. There is a clear system for the recording of service users’ monies. Each service user has a bank account and records and receipts of purchases demonstrate how money is spent. St Barbara`s Walk (35) DS0000007566.V366819.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is homely, comfortable and clean and provides service users with spacious, private and communal space in which to live. EVIDENCE: The service is situated in an ordinary house set in a terrace of other houses within an area that is attractive and close to community facilities. Each service user has their own room that is individually decorated and furnished to reflect their choice and personality. The décor and furnishing throughout the home are attractive and well maintained. Service users have their own key to lock their bedroom. They also have keys to the front door of the house. Locked facilities are available within individual bedrooms for the protection of personal possessions and medication. St Barbara`s Walk (35) DS0000007566.V366819.R01.S.doc Version 5.2 Page 20 The house was clean and tidy throughout and there were no presenting health and safety issues. The home received positive feedback from the fire service regarding the comprehensive fire risk assessments that are in place during their last visit. The fixed and portable electrical and gas appliances/installations are serviced and certified as required by legislation and where gas appliances are not room sealed, carbon monoxide detection is available for added safety. In addition to this weekly tests of all emergency detection and lighting installations are carried out and recorded by the home. A comprehensive maintenance programme is in place to maintain the good standard of the home. St Barbara`s Walk (35) DS0000007566.V366819.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A competent well-trained staff team who are committed and enthusiastic in their role and recruited following robust recruitment procedures, supports service users. EVIDENCE: Staff are up to date with mandatory training and all but 2 have achieved NVQ 2, some are working towards NVQ 3 and 2 towards NVQ4. This provides good skilled and experienced staff to address the needs of service users living here. Although there is a low turnover of staff there are 2 current vacancies that have been advertised and there a plans for interviews to take place soon. Apart from these posts there has been no recently recruited staff to the home. Staff are recruited following the organisation’s robust procedures and application forms 2 references and a CRB check are kept on file. St Barbara`s Walk (35) DS0000007566.V366819.R01.S.doc Version 5.2 Page 22 All new staff shadow experienced staff as part of their three-month probationary period and all staff have clearly defined job descriptions. A good training programme is available for staff to follow. Staff work towards achieving accredited qualifications in the Learning Disability Award Framework, makaton vocabulary, managing behaviour, safe handling of medications, safe use of recovery medications for epilepsy emergencies, safeguarding adults and working with older people with a learning disability. The organisation has 2 designated staff responsible for coordinating training. The training opportunities offered to staff reflect the needs of the service group but the organisation is also keen to support staff to develop in other areas for the benefit of the service users, for example information technology and driving. St Barbara`s Walk (35) DS0000007566.V366819.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager, who is well supported by his staff team, provides good leadership and runs a service that has effective monitoring systems that are focussed on the best interests of the service users. EVIDENCE: The manager has managed this home since it opened and is qualified in the Diploma of Nursing Studies. He is currently completing the Registered Managers Award and hopes this will be finalised 10th July this year. He is a NVQ Assessor and has recently attended a wide range of training including clinical supervision, first aid, the Mental Capacity Act, food hygiene, dementia care and safeguarding adults. St Barbara`s Walk (35) DS0000007566.V366819.R01.S.doc Version 5.2 Page 24 The manager and his staff team follow comprehensive policies and procedures that are focussed on supporting people in their care to live ordinary lives. Service users’ independence has been promoted and supported positively in a safe way resulting in them all enjoying lives that are valued and interesting. Good health and safety systems are in place and staff work in a way that reflects these. All of the records kept are generally up to date, however the manager and staff recognise where improvements can be made. Although staff regularly monitors the care and management systems in place and it is evident that the service is run in the best interests of the service user, there is no formal quality assurance system in place. The manager is aware of this and has plans to address this as part of further improvements to this service. St Barbara`s Walk (35) DS0000007566.V366819.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 X 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 3 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 4 13 4 14 X 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 3 X 3 X X 3 X St Barbara`s Walk (35) DS0000007566.V366819.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 YA6 YA39 Good Practice Recommendations The monthly monitoring of individual care plans should be recorded in the specified place in the care plan document. It is recommended that the home undertake surveys of residents, visitors of visiting professionals to find out their views of the home and the care provided. St Barbara`s Walk (35) DS0000007566.V366819.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Barbara`s Walk (35) DS0000007566.V366819.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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