Inspection on 05/09/06 for Strothers Road

This inspection was carried out on 5th 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Strothers Road 07/02/06

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Blenheim House

Prince Bishop Court

Park View (15)

Craigmore House

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

CARE HOME ADULTS 18-65 Strothers Road Strothers Road Care Home 15-18 Strothers Road High Spen Rowlands Gill Gateshead Tyne and NE39 2HR Lead Inspector Mrs Elsie Allnutt Key Unannounced Inspection 5th September 2006 09:30 Strothers Road DS0000065006.V309123.R02.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 Strothers Road DS0000065006.V309123.R02.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. Strothers Road DS0000065006.V309123.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Strothers Road Address 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) Strothers Road Care Home 15-18 Strothers Road High Spen Rowlands Gill Gateshead Tyne and NE39 2HR 01207 549706 www.c-i-c.co.uk. Community Integrated Care Mrs. Mairi Turner Care Home 4 Category(ies) of Learning disability (3), Physical disability (1) registration, with number of places Strothers Road DS0000065006.V309123.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th February 2006 Brief Description of the Service: 15-18 Strothers Road is a purpose-built service that provides accommodation and care for up to 4 people with learning disabilities. The accommodation is an outcome of a planned transition programme for the four current service users who previously lived in Prudhoe Hospital. The Health Care Trust and Gateshead Social Services who contracted with Community Integrated Care (CIC), a Charity Organisation, to deliver the service, implemented the resettlement programme. The building was built and is owned by Three Rivers Housing Association. It is divided into three flats, which are self-contained and have their own front entrance and back gardens. Two service uses share one flat and the other two have individual flats. One is situated on the first floor and is not accessible to service users with physical disabilities. They all provide individual bedrooms for the service users, a bathroom, toilet, kitchen, lounge and dining area. A fourth flat on the first floor is used to accommodate facilities for staff including an area where administrative duties can be carried out. The home was specifically designed for the people who live there. There is good access into and around all areas of the home, which are connected with stairwells and passageways with doors separating the different flats. It is a modern building that offers wide corridors and accessibility on the ground floor that can accommodate a wheelchair. There is level access to the front of the building and to two of the flats, approached by separate pathways that are divided by small garden areas. The third flat is accessed by stairs from an inside hallway. Each flat has a separate garden at the rear of the building easily accessed from inside and there is a large driveway to the side of the building that can accommodate several cars. A fence runs around the perimeter of the building but the look from the outside is that of a small terrace of three houses. This blends in with other small old terraces of houses in the area and newer houses that are also being developed in this area of High Spen. There are a few local shops and bus routes to local areas of beauty and into Newcastle and Gateshead. The home has developed a Service User Guide that informs prospective service Strothers Road DS0000065006.V309123.R02.S.doc Version 5.2 Page 5 users about the service, the aims and how these are met. A copy of the recent inspection report is available in the home for anyone to read. The fees charged by the home are £2,694 per week. Strothers Road DS0000065006.V309123.R02.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. Questionnaires were sent out to service users’ relatives prior to the inspection and three were returned. All indicated that they were satisfied with the service delivered. The views of the four service users and five members of staff were sought. As all of the service users do not have effective verbal communication their satisfaction of the service was interpreted through the observations of body language, interaction with staff, discussions with staff and the examination of records. This process demonstrated that all were satisfied with the service and the care and support given by staff. What the service does well: The manager and her staff team have worked hard with other professional people from health and social care to make the move from living in a hospital to living in a house in the community as easy as possible. Due to everyone talking and listening together this has worked very well. The service users live in separate flats that have plenty of space to move around and have good quality furniture. The rooms are nicely decorated and the colours of the walls make the rooms look warm, calm but cheerful. This means that service users live in a comfortable and attractive home. Staff have helped service users to choose ornaments and pictures they like to put in their flats. These make the flats look different and personal. Some service users have also chosen to keep a pet. One service user has a gold fish and another two service users have a rabbit that they keep in their garden and staff help the service users to look after them. The flats are well looked after and are kept clean as a result of good cleaning routines. This means that service users live in a clean place. Staff talk to service users and help them to do the household chores. This helps service users to take control over their lives. One service user greeted the inspector at the door with a friendly handshake. The large number of staff on duty during the day means that service users can take part in different activities, both in the home and outside, with the level of support they need. This helps service users to live an interesting lifestyle and it also helps them to keep in contact with their family and friends. Family and friends are made welcome when they visit. Strothers Road DS0000065006.V309123.R02.S.doc Version 5.2 Page 7 Many of the staff have worked at Strothers Road since it opened and now know the service users well. All of the staff are taught how to support and care for people with learning disabilities. This means that service users receive the right kind of support. What has improved since the last inspection? What they could do better: So that the flats are kept in good repair the inside walls that are damaged should be repaired in a way that prevents them being easily damaged again. This will mean that the sort of behaviours sometimes demonstrated by service users will have less affect on the environment. The bathrooms could be made to look more inviting and warm with the addition of small furnishings and pictures. This will make these areas more attractive and warm looking for service users. So that staff know what to do if there was a fire, when first employed they should be given instructions about the home’s fire procedures on two occasions during their first month of employment at the home. The manager must make sure that a full staff team is employed, so that there are enough staff that know service users well to work each day. Strothers Road DS0000065006.V309123.R02.S.doc Version 5.2 Page 8 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. Strothers Road DS0000065006.V309123.R02.S.doc Version 5.2 Page 9 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 Strothers Road DS0000065006.V309123.R02.S.doc Version 5.2 Page 10 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): 2,5 Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to the service. Good multidisciplinary preadmission assessments are in place that demonstrate service users’ needs and aspirations and that determined the home could offer service users, now living there, an effective service. So that service users are aware of the terms and conditions of their residency they are issued with a Contract that informs them of the full cost of the fees to be paid. EVIDENCE: As part of the transition process from a hospital environment to a home in the community, a team of health and social care professionals carried out detailed assessments, identifying individual service users’ needs, aspirations and any assessed risks. Staff confirmed that prior to the move they worked closely with the hospital staff and other professionals with the aim of getting to know the prospective service users, while at the same time they carried out their own assessments. The information gathered was used to develop individual care plans and the manager stated that the background information provided the staff team with a good insight and understanding of individual needs and behaviours. Strothers Road DS0000065006.V309123.R02.S.doc Version 5.2 Page 11 To ensure that the transition process continues to develop positively the manager stated that health professionals continue to work closely with the staff team assessing changing needs evident since the move. An occupational therapist visited the home during the inspection process as a planned visit to re-assess one of the service users. The related assessment documents are in place in the residents care files, which give full details of the level of support needed and any risks that may be evident. A summary of the Residents Contract, in picture format explaining the terms and conditions and full cost of their stay, is now included in their care files. A representative of CIC and a representative of the service user have signed the original document which also includes a break down of who is responsible for paying the fees and the individual agreements regarding the use of an individual’s mobility allowance. Strothers Road DS0000065006.V309123.R02.S.doc Version 5.2 Page 12 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 the service. Each service user has a care plan that is easy to understand considers all areas of their lives and includes risk assessments. EVIDENCE: The manager and staff team have worked hard to develop a good care planning system to incorporate guidance given by the professionals involved in individual service user’s lives. They cover health, welfare and social issues and any identified risks are addressed and reduced by risk management plans being put in place. The home is in the process of further developing the care-plan system so that they are service user led and recorded with a person centred approach. Pictures support the care plans in an attempt to make them more accessible to the service users. The guidelines in the care plans clearly identify the amount of support service users need with different tasks while at the same time promote service users as people with dignity and self direction. Strothers Road DS0000065006.V309123.R02.S.doc Version 5.2 Page 13 The opening of the care plan provides a photograph of the individual service user with their Life Story surrounding it. This is an excellent way of seeing service users as they are and where they are at in their lives and will be useful for the reader of the plan to see the person, their strengths and their needs, at a glance Staff and observations confirmed that service users’ independence is promoted and they are encouraged to take control over their own lives. Records confirmed this and action plans describing how personal goals are to be achieved were in place. For example how a service user needs to further develop their communication skills is recorded and guidelines how this can be achieved with the support of staff, are in place from the Speech Therapist. Records also confirmed that the care plans are monitored by the service user and their key worker monthly and reviewed six monthly when other people involved in their lives are invited to attend. Strothers Road DS0000065006.V309123.R02.S.doc Version 5.2 Page 14 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): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Although the people who live at this home have complex needs, their right to choice and to live a normal life as possible is sensitively developed and promoted. As a result service users live a varied lifestyle both at home and in the community while maintaining contact with family members and friends. The food is of good quality and sufficient to meet the needs of service users. EVIDENCE: A high ratio of staff supports, promotes and enables service users to engage in individual activity programmes, both in the home and in the local community. It is clear that much work has gone into organising a staffing structure that is appropriate in ratio to support and address individual service users’ complex needs when taking part in different activities. Care plans demonstrate how this is achieved clearly recording how an activity is organised and how many staff are needed to support the service user. For example one service user in their care plan stated, “I like to go for short walks.” The number of staff Strothers Road DS0000065006.V309123.R02.S.doc Version 5.2 Page 15 needed to support this is recorded and clear guidelines are in place for staff to follow, directing them towards the level of support needed at different points of the activity. Care plans include lists of activities service users like and dislike, however staff stated that new experiences are regularly introduced. A member of staff said, “we introduce new experiences carefully and sensitively, choosing the right times when we know an individual’s mood is right. We want the experience to be successful.” The member of staff related this to an event where staff successfully supported one service user to enjoy a shopping experience when previously this had been an activity that promoted challenging behaviours. Guidelines are now in place for staff to follow to ensure that future shopping trips are as successful. Records demonstrate how staff encourage service users to keep in contact with their families and friends. Although there were no relatives visiting the home at the time of the inspection, surveys sent out to relatives prior to the inspection, confirmed that families are kept up to date about their relative’s welfare. One service user’s care plan described the different clubs and events they attend to meet up with old friends. Another recorded how another service user supported by staff keeps a relative who lives some distance away, informed of their progress. A sample of menus demonstrates that a variety of meals are provided using fresh food, vegetables and fruit. The manager and records confirmed that a dietician guides staff in relation to service users’ individual dietary needs. Strothers Road DS0000065006.V309123.R02.S.doc Version 5.2 Page 16 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 the service. Service users personal and healthcare needs are met in a flexible but consistent manner, with the aim of allowing service users to take the lead. Medication arrangements are appropriate for the needs of service users and are managed in a safe manner. EVIDENCE: Staff support service users to address their individual healthcare needs by assisting them to visit local GPs and attend hospital appointments. The outcomes of such visits are recorded in individual care files. Two service users were observed being supported by staff to attend a doctor’s appointment and an optician’s appointment in the local community. The manager stated that some service users due to there complex needs attend dentist appointments at the local hospital or the dentist provides home visits. The observation of the interaction of staff with service users demonstrates that personal support is delivered in a discreet and respectful manner. However due to service users’ occasional challenging behaviours a more stern approach was also observed. Strothers Road DS0000065006.V309123.R02.S.doc Version 5.2 Page 17 Records confirmed that specialist healthcare professionals are involved in service users lives where appropriate. One service user’s care plan includes guidelines from a physiotherapist and speech therapist. The manager has received positive feedback from the Learning Disabilities Community Healthcare Team, who stated that they enjoy working with staff at the home as they are confident that the advice and guidance given is used effectively in the care plan process and as a result reflects good care practice. Letters in individual care files from other healthcare professionals reflect improvements made in relation to individual service user’s general wellbeing and behaviours. Observations also confirmed this. The manager stated that this is the result of staff following the guidelines set and supporting service users in a consistent way. Staff and records confirmed that they have received training in relation to service users’ needs. This includes Introduction to Autism, Mental Health Awareness, Challenging Behaviour, MAKATON and Using Picture and Symbols to Communicate. Staff and records also confirmed that they have received training in relation to the administration of medication. The medication is appropriately recorded and stored. Strothers Road DS0000065006.V309123.R02.S.doc Version 5.2 Page 18 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 the service. Arrangements are in place to help protect service users from abuse and to seriously address complaints and concerns about the service. However, although the home has demonstrated that they follow the correct procedures when abuse is reported, as a result of two accounts of theft in the home, service users have been put at risk. EVIDENCE: The home has a comprehensive Complaints Procedure, a copy of which has been given to each service user in picture format. The manager stated that copies of the procedure have also been sent to service users’ relatives and advocates. There have been no complaints made since the last inspection however three compliments were recorded. These include compliments from a service manager, a relative and a health care professional. All complimented the home on their good care practices. Staff spoken to confirmed that they received awareness training regarding abuse and adult protection, as well as training in relation to handling verbal and aggressive behaviour. The manager confirmed that there are plans for all staff to attend training with the local authority in relation to their Adult Protection Procedures. Some staff confirmed that this has been completed and there are plans in place for the remaining staff to attend. A copy of the local authority procedures is available in the home. Strothers Road DS0000065006.V309123.R02.S.doc Version 5.2 Page 19 There have been two accounts of theft in the home since the last inspection. One included money stolen from a service user and another from a member of staff. Appropriate procedures have been followed by the home, these include a police investigation, a referral of the incidents to the appropriate agencies including CSCI and putting improved practices in place. Neither incident has been solved but police investigations continue. Individual service user’s monies are kept in a locked safe, recorded appropriately in individual records and signed for by two staff when withdrawn. Receipts are kept of all transactions. Only senior staff now have access to the money. Staff are provided with lockers to lock away their valuables while at work. It has been the home’s practice to leave the front doors unlocked, however the surrounding area to the home includes other businesses where members of the public come and go. The home and the people in it therefore must be kept safe by securing the entrances into the home. A discussion took place with the manager in relation to how this can be discreetly achieved but avoiding institutional practices. The manager agreed to address this issue with staff. Strothers Road DS0000065006.V309123.R02.S.doc Version 5.2 Page 20 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): 24,27,30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Service users benefit from a well-maintained, homely, safe and clean accommodation that has been specially designed and built to meet their individual needs and lifestyles. EVIDENCE: Each flat was designed and furnished to address individual need determined by the outcome of a multi agency assessment. All of the rooms meet the National Minimum Standards in size except for one bedroom that is purposefully small. This is in response to the outcome of the preadmission assessment and the guidance of the service user’s family and professionals involved in their care. However the manager stated that this is regularly reviewed and will be reconsidered in the event of changing needs. The same service user also has an individual bathroom and activity area, as well as a large living area that is comfortably furnished with direct access into a garden courtyard. . Staff have supported service users to gradually introduce small furnishings and personal items to their individual living areas that reflect their individual personalities. One service user has decorated their walls with family Strothers Road DS0000065006.V309123.R02.S.doc Version 5.2 Page 21 photographs and staff support three service users to care for pets, a goldfish and a rabbit. As these additions to the individual living areas help to create a warm and homely atmosphere a discussion took place with the manager in relation to how the bathrooms could be improved in the same way. The addition of mirrors and small furnishings could help the bathroom areas to look more inviting and warm. All of the service users were observed to be comfortable, safe and content in their different environments. The size of the rooms address the space service users need and all have small, secluded gardens that they can easily access. There were areas in one of the flats where walls have been damaged as a result of doors banging hard against them. During the inspection the manager and a maintenance person discussed the best way of reinforcing these areas, as part of the repair work, in an attempt to avoid further damage. One service user with physical needs has a ground floor flat that is suitably furnished with the adaptations and equipment that they need. All staff are aware of and have attended training in relation to Infection Control and the laundry facilities, that are suitably equipped with washing machines and dryers, are sighted separately from the kitchen areas. All areas of the building were clean and tidy, this reflects effective cleaning routines. Strothers Road DS0000065006.V309123.R02.S.doc Version 5.2 Page 22 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): 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 the service. The staffing ratio meets the high and complex needs of the people using 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: Staff were observed working competently and with interest. The manager and 7 members of staff, including 1 senior, were on duty. Considering the complex needs of the people using this service this is an adequate number. Examination of the staffing rota documents confirmed that this number is maintained, although the manager stated that one member of staff is used flexibly so that enough support is available to accommodate individual service users’ needs and activities. Individual care plans record how many staff are needed to safely support service users with personal tasks and during different activities. The manager stated that currently there are 2 staff vacancies, however the manager confirmed that these are soon to be addressed, as one person is to transfer from another of the Company’s homes and four new job applications Strothers Road DS0000065006.V309123.R02.S.doc Version 5.2 Page 23 have been received. The importance of having a full team was discussed with the manager. The manager and her senior staff have worked hard to establish an improved administrative system that accommodates well-ordered staff records that are easy to access. These include individual training and supervision records as well as recruitment records. Of the files examined all confirmed that staff are up to date with mandatory training and have attended training related to service users individual needs, for example MAKATON, Signs and Symbols and Values and Advocacy. They also confirmed that the homes robust recruitment procedures are followed. Application forms, adequate references and CRB checks were in place in the files examined. Strothers Road DS0000065006.V309123.R02.S.doc Version 5.2 Page 24 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 the service. The manager who is experienced, hard working and well supported by her 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 registered manager who has many years experience of managing care services, is also fully qualified to carry out her role, having successfully completed the Registered Managers Award and NVQ4 in Care. So that the staff team is lead with a progressive approach the manager confirmed that she regularly attends training related to good care practices and keeps up to date with changes in legislation. She stated that she has recently attended a five day course on Person Centred Approach, and that she is a Moving and Handling Facilitator and a Fire Trainer. Other courses the manager Strothers Road DS0000065006.V309123.R02.S.doc Version 5.2 Page 25 has attended are related to individual needs of the service users for example Autism and specialised communication methods. Observations and discussions with service users and staff confirmed that effective relationships have developed between service users, staff and the manager. Service users and staff were observed interacting with the manager with confidence and respect. A Quality Assurance System is in place that assures quality monitoring throughout the service. The manager confirmed that the views of service users and their families is an important part of the monitoring system and as an outcome a report is compiled at the end of the year. Staff were observed to work appropriately regarding health and safety procedures and the appropriate health and safety records were satisfactorily complete. However one file of a recently recruited member of staff did not confirm that the person had received two sessions of fire instruction in their first month of employment as recommended by the Fire Brigade. This was brought to the attention of the manager who agreed to address it. The success of the transition period and the development of the service and that of individual service users over the first 12 months of this service is a reflection of the commitment and hard work of the manager and staff team and the way they have worked in partnership with health and social care professionals. Strothers Road DS0000065006.V309123.R02.S.doc Version 5.2 Page 26 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 4 3 x 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 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 X 33 3 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 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 3 X 3 3 X 2 X Strothers Road DS0000065006.V309123.R02.S.doc Version 5.2 Page 27 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 YA23 Regulation 13(6) Requirement The registered manager must ensure that the plans for all staff to attend training in relation to the local authority’s Protection of Vulnerable Adults (POVA), procedures must go ahead. The registered manager must address the security of the home and how best this can be maintained. The registered manager must address the security of the home and how best this can be maintained. The registered manager must address the security of the home and how best this can be maintained. The plans to repair the damaged walls must go ahead and plans to find a solution to avoid further damage should be put in place. To ensure continuity of care the registered manager must address the current staff vacancies. All newly recruited members DS0000065006.V309123.R02.S.doc Timescale for action 30/11/06 2 YA23 13(4)(c ) 30/09/06 3 YA24 13(4)(c ) 30/09/06 4 YA42 13(4)(c ) 30/09/06 5 YA24 23(2) 12(4)(a) 30/09/06 6 YA33 18(1)(a)(b) 30/09/06 7 YA42 23(4)(d)(e) 30/09/06 Page 28 Strothers Road Version 5.2 of staff must receive at least 2 instructions in relation to the home’s fire procedures, in their first month of employment. 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 YA16 Good Practice Recommendations A risk assessment should be carried out in relation to having locks on the bedroom doors of the service users sharing accommodation. Consideration should be given to the addition of small furnishings to the bathrooms that could result in improving their look and feeling of warmth. 2 YA27 Strothers Road DS0000065006.V309123.R02.S.doc Version 5.2 Page 29 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 Strothers Road DS0000065006.V309123.R02.S.doc Version 5.2 Page 30 - 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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