Inspection on 07/02/06 for Strothers Road

This inspection was carried out on 7th February 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Strothers Road 05/09/06

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 Announced Inspection 7th February 2006 10:00 Strothers Road DS0000065006.V282216.R01.S.doc Version 5.1 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.V282216.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V282216.R01.S.doc Version 5.1 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 Care Home 4 Category(ies) of Learning disability (3), Physical disability (1) registration, with number of places Strothers Road DS0000065006.V282216.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 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 serivce users who previously lived in Prudhoe Hospital. The resettlement programme was implemented by the Health Care Trust and Gateshead Social Services who contracted with Community Integrated Care (CIC), a Charity Organisation, to deliver the service. The building was built and is owned by Three Rivers Housing Association. It is divided into three units, which are self-contained and have their own front entrance and back gardens. Two service uses share one unit and the other two have individual units. One of the units is situated on the first floor and is not accessible to service users with physical disabilities. The units provide individual bedrooms for the service users, a bathroom, toilet, kitchen, lounge and dining area. A fourth unit 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 stair wells and passage ways with doors between the different units. 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 units, approached by separate pathways divided by small garden areas, the third unit is accessed by stairs from an inside hallway. Each unit 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. Strothers Road DS0000065006.V282216.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection to take place at this home since it was registered with the CSCI and opened in September 2005. It was an announced inspection and took place over one day in February. Time was spent with service users and staff, and a tour of the building took place. Some time was also spent checking care, health and safety, and staff records. The views of the service users and members of staff were sought. Service users’ satisfaction of the service provided not only relied on verbal communication but it was also interpreted through observations of body language, interaction with staff, discussions with staff and the examination of records. This process demonstrated that all were still in the process of settling into their new way of life and new accommodation but also demonstrated that they were satisfied with the service and the care and support given by staff. What the service does well: The people who use this service have individual complex needs and have previously lived in a hospital environment for many years, the transition process into community living was therefore very important. As a result of careful planning and effective teamwork between the home and the different agencies this has been successfully achieved. Relatives of service users commented favourably about the transition process and how well it had gone. They stated that they had been consulted during the transition planning process and felt that this had been carried out successfully. They also stated that they had regularly visited the site with their relative during the actual building process. The service provides accommodation of a good standard. The furniture and fittings are of a good quality and the décor offers a warm, calm but cheerful environment. The manager and staff stated that the complex needs of the service users were addressed sensitively in the transition process and this was achieved by introducing the change of environment gradually, for example: the design and décor of the building was considered in relation to the service users’ needs; visits were made to the building prior to moving in; information was shared by hospital staff with staff from the home prior to the move; and once the move took place different pieces of small furnishings were gradually introduced to make the individual units look individual and homely, this process continues. The units are well maintained and as a result of effective cleaning routines offer clean and hygienic environments. Strothers Road DS0000065006.V282216.R01.S.doc Version 5.1 Page 6 The manager explained that the aim agreed with the Transition Team was to remain with the care plans developed around the hospital structure for the first three months and gradually develop daily routines and activities with the aim of developing autonomy encouraging service users to take control for example taking part in housekeeping tasks. Staff stated that one service user “has short bursts of hoovering and baking with the goal of eventually completing the task.” A review carried out by the multi disciplinary team recently recorded that “ now has more control over their environment.” By observing life in the home it was evident that service users are supported to live a full and active lifestyle. Service users were involved in different activities during the day that included a walk in the local woods, a drive out in the car, shopping for food and a visit to the home by relatives. Staff were observed interacting with service users in a positive and dignified way. They work with respect and skill and involve service users in making their own choices about what they prefer to do. A mutual respect was observed between staff and service users. Relatives commented, “the staff are good and have worked hard during the transition process.” What has improved since the last inspection? What they could do better: Service users’ have been given individual Service Contracts, however these must include the full cost of their fees and explain who is responsible for paying them. This will give the service user and their family or advocate the full written information about the full cost of the service and how this is paid. To reflect the good care practice delivered and the good relationships developed between other professional agencies, the guidance and advice given in relation to individual service user’s care must be used to develop informative and effective care plans that will guide staff in their care practices. Service users will benefit from this by receiving support and care in a consistent way. So that service users are safeguarded by robust recruitment procedures references that are vague and do not give the information about the applicant as required should be followed up and original CRB documents must be kept to be examined by a CSCI Inspector. The level of staff support needed to address the needs of the service users when carrying out their plan of care must remain at the agreed level of 7 staff on duty during the day and 3 on waking night duty. This is to enable service users to develop interesting and valued lifestyles in the local and wider communities. Strothers Road DS0000065006.V282216.R01.S.doc Version 5.1 Page 7 To protect the dignity and privacy of service users, consideration should be given to putting locks on the bedroom doors of the two service users who share one of the units and so that service users eat healthily and have a choice in what they eat the current menus should be reviewed. The Company’s Policies and Procedures that have been transferred to this service should be reviewed, dated and adapted where necessary so that they guide staff in relation to the aims and objectives of this particular service. 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.V282216.R01.S.doc Version 5.1 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 Strothers Road DS0000065006.V282216.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 The home provides information that assists prospective service users to make an informed choice about where to live and in order to determine that the home can meet their needs and provide a lifestyle of their choice, service users needs and aspirations are assessed prior to admission. So that service users are aware of the terms and conditions of their residency they are issued with a Contract, however this document neglects to inform service users of the full cost of their stay, which could lead to confusion. EVIDENCE: The home has developed a comprehensive Statement of Purpose and Service User Guide, the latter is illustrated with photographs and pictures, so that service users have access to information that they understand, about the home and the service delivered. So that the home was confident that they could meet the needs of the service users a team of health and social care professionals carried out full assessments of service users’ needs prior to a decision being made for them to move into the home. 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. Strothers Road DS0000065006.V282216.R01.S.doc Version 5.1 Page 10 A summary of the Residents Contract is also in the files. Although this includes the amount of money the service user has to pay towards the cost of their fees, this does not include the full cost of the fees, nor does it identify who is responsible for paying the remaining costs. A representative of CIC and a representative of the service user have signed the document. Strothers Road DS0000065006.V282216.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9,10 Care practices ensure that service users’ individual needs are addressed appropriately and that they are encouraged and supported to live their preferred lifestyle as independently as possible. Although a wide range of information is contained in the service users’ care files and the assessment information is comprehensive, the care plans developed by the home are vague and lacking in guidance. There is a risk therefore that care delivered will be inconsistent. EVIDENCE: The home has care plans in place for each service user, however these are lacking in detail in relation to how the assessed needs are to be met. The manager stated that staff are currently following the hospital’s care plans, these are comprehensive and offer clear guidance, however the manager and staff also confirmed that some of the needs identified by the hospital have changed over the past six months and since the service users have moved in this environment. Strothers Road DS0000065006.V282216.R01.S.doc Version 5.1 Page 12 So that the care delivered is appropriate and staff are consistent in their approach and delivery of care, it is important that the home develops clear care plans that are effective and based on the information given during the preadmission assessment period and the home’s observations and assessment carried out since moving into Strothers Road. Risk assessments are in place and include guidelines for staff to follow in relation to reducing the risk. A discussion took place with the manager regarding how these could be effectively used as an integral part of the care plan. The manager was receptive to this. A personal profile and Person Centred Plan for each service user is included in the individual care files, these clearly identify service users’ likes, dislikes and lifestyle preference which guides staff when supporting them to make choices and decisions. The manager confirmed that service users have an independent advocate who in addition to staff, are actively involved in supporting their needs and achieving their personal goals. Records confirm that staff are aware of and understand the home’s policy on confidentiality. Strothers Road DS0000065006.V282216.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Although the people who live at this home have complex needs, their right to choice and to live a normal life as possible is being sensitively developed and promoted. This is achieved by taking part in daily activities in the home as well as inclusion in community-based activities, while at the same time encouraging contact and involvement with family and friends. In addition a healthy lifestyle is also promoted by developing a healthy choice of meals. 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. Although 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, how this process is achieved is not included in a care plan structure. However a good working relationship has developed between the home’s staff and other professionals. This has provided important information regarding Strothers Road DS0000065006.V282216.R01.S.doc Version 5.1 Page 14 the needs of the service users and how they should be addressed. An Occupational Therapist has given clear written guidance for staff to follow in relation to this that could be used as guidance for staff to follow in the care plans when supporting service users with activities. A discussion took place with two relatives of service users who were complimentary about the way they are welcomed into the home and included in their relative’s life and care programme. Although all of the service users have the opportunity of having keys to their front doors, consideration should be given to having locks on the bedroom doors of the two service users who share a flat. A risk assessment should be carried out in relation to this. A sample of menus demonstrate that a variety of meals are provided, however a discussion took place with the manager in relation to using more fresh produce and addressing the needs of individual service users in relation to food tolerance. This was particularly with reference to service users demonstrating challenging behaviour and hyperactivity. The manager stated that the menus were to be reviewed and the advice of a dietician was to be sought. Strothers Road DS0000065006.V282216.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Service users health care needs are identified and arrangements put in place to ensure that they are promoted and met. However the good care practice delivered is not reflected in the care plans. There are good systems in place regarding the safe administration of medication that promote the safety of service users. 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. The observation of the interaction of staff with service users demonstrates that personal support is delivered in a discreet and respectful manner. Staff were observed offering support sensitively and appropriate to the needs of the individual service users. Locks on toilet and bathroom doors promote individual service user’s privacy and dignity, and when one service user was observed behaving inappropriately a member of staff was observed promoting their privacy and dignity by discreetly assisting them behind a closed door. Strothers Road DS0000065006.V282216.R01.S.doc Version 5.1 Page 16 However the such good care practices were not reflected in the care plans. There was no detail how a service user preferred to be supported or the amount of support they actually needed. Neither was it recorded how they might respond to different healthcare situations, for example visiting the dentist or chiropodist. Staff confirmed that they have received training in relation to the administration of medication and observation on the day confirmed that the procedures were appropriately followed. Strothers Road DS0000065006.V282216.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The home has a Complaints Procedure, that is also in picture format in an attempt to make it accessible to service users. This ensures that concerns and complaints will be taken seriously. However so that service users are also protected and supported by people involved in their lives, relatives/advocates must be made aware of the procedures. So that service users are fully protected from abuse the home follows the local authority’s procedures on Adult Protection. EVIDENCE: The home has a comprehensive Complaints Procedure a copy of which has been given to each service user in picture format. The manager agreed to give service users’ relatives and advocates a copy. Staff spoken to confirmed that they have received awareness training regarding abuse and adult protection, as well as training in relation to handling verbal and aggressive behaviour. The manager confirmed that all staff are currently attending training with the local authority in relation their Adult Protection Procedures. A copy of the local authority procedures is available in the home. Strothers Road DS0000065006.V282216.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 Service users benefit from well maintained, homely, safe and clean accommodation that has been specially designed and built to meet their individual needs and lifestyles. EVIDENCE: The building is divided into three separate units where two service users share one and two other service users have a unit each. Each unit 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 something that will be reviewed and reconsidered in the event of changing needs. 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. Strothers Road DS0000065006.V282216.R01.S.doc Version 5.1 Page 19 One service user with physical needs has a unit on the ground floor 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. Strothers Road DS0000065006.V282216.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 The staff employed are well trained, competent in their role and receive appropriate supervision to ensure that all aspects of individual service users needs are met. However the total number of permanent staff employed should meet the demand of the high ratio of staff needed. By avoiding the general use of Bank or Agency staff will promote a more consistent delivery of care to service users. So that service users are protected the recruitment procedures must be rigidly followed. EVIDENCE: Staff confirmed that they have been issued with job descriptions and are aware of the GSCC (General Social Care Council) Codes of Practice and how they relate to their care practice. One new member of staff stated that their role, as described in the job description, was now becoming clearer with the support and guidance received from other team members, the manager and training opportunities. Although staff were observed to work with care and skill they were aware of their limitations and confirmed that they look for further guidance and advice from the manager and professionals involved in the care of the service users. The daily staffing ratio is currently enough in number to address the complex needs of the service users. Although the need for this number was originally assessed by health and social care prior to the service opening with the proviso Strothers Road DS0000065006.V282216.R01.S.doc Version 5.1 Page 21 that it would be reviewed after the first six months, it is evident that in order to maintain the level of support and care needed, while at the same time develop active and valued lifestyles that offer social inclusion, the minimum level of 7 staff on duty during the day and 3 on waking nights is needed and must remain. In the event of care needs changing over time the issue of reducing staffing numbers must be discussed with relevant agencies including the CSCI. A sample of staff files was examined and concerns in relation to these were raised with the manager. The files were disorganised causing difficulty in accessing various documents. Recruitment documents were in place however one reference was vague and did not give a transparent report in relation to the member of staff’s suitability for the job or their skills and qualities that were evident in their previous role. One reference only was available for another employed member of staff. The manager must ensure that each applicant has two references and they are appropriate and give enough information about the applicants’ abilities and qualities so that an informed judgement can be made. Photocopies of staff’s’ criminal record checks (CRB documents) were in place, however the manager was advised that when a member of staff is recruited the original CRB document must be kept so that it is checked by CSCI during the inspection nearest to the date of recruitment. An agreed time was arranged to examine these documents after the inspection. Staff confirmed that they had received training in relation to issues surrounding the needs of the service users prior to and since starting work at Strothers Road. Staff felt that this had equipped them to carry out their duties confidently. Records confirmed this and the manager confirmed that each member of staff had a training plan. A training matrix confirmed what training had taken place and what was arranged for a later date. Almost 50 of staff have achieved NVQ. Strothers Road DS0000065006.V282216.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 42, 43 A well-managed staff team promotes the health and safety of the service users however the Company’s policies and procedures have not yet been reviewed to ensure that they are pertinent to this service. This could mean that the rights of the service users’ using this service are not safeguarded appropriately and the aims and objectives of this particular service may not be fulfilled. EVIDENCE: The manager is currently going through the registration process with the Commission for Social Care Inspection to be Registered Manager for this home. She has four years experience of managing services for people with learning disabilities and was previously the Registered Manager for another Community Integrated Care (CIC) home. She is suitably qualified having achieved the Registered Managers Award and NVQ 4 in Care. The manager also confirmed that since moving into this post she has attended training with the staff team in relation to the individual needs of the service users as well as becoming a Moving and Handling Facilitator and Fire Safety Trainer. Strothers Road DS0000065006.V282216.R01.S.doc Version 5.1 Page 23 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 will be an important part of the monitoring system and as an outcome a report will be 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. The success of the transition period 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.V282216.R01.S.doc Version 5.1 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 3 2 3 3 3 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 2 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 2 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 2 3 3 2 X 3 3 Strothers Road DS0000065006.V282216.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? N/A 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 YA5 Regulation 5(b) Requirement Service users’ Contracts must include the full cost of their fees and explain who is responsible for paying them. Care plans must be developed so that they clearly identify how the current needs of the service users are to be met. The guidance and advice given by the professionals involved in individual service user’s care must be used in the care plans to consistently guide staff in their care practices. The amount of support needed to address the individual care and healthcare needs of service users and the way they prefer to be supported during this, must be recorded in the care plans. So that service users’ families and advocates are aware of how to raise concerns or make a complaint a copy of they must also receive a copy of the Complaint Procedure. So that the assessed needs of the service users are appropriately addressed the DS0000065006.V282216.R01.S.doc Timescale for action 31/03/06 2 YA6 YA14 & YA15 YA16 15(1)(2) & 13(b) 31/03/06 3 YA17Y & A18 15(1)(2) 31/03/06 4 YA22 22(5) 31/03/06 5 YA33 18(a)(b) 31/03/06 Strothers Road Version 5.1 Page 26 6 YA34 19(4)(b) 19(4)(c ) minimum level of 7 staff on duty during the day and 3 on waking nights must remain and the amount of permanent staff employed must effectively cover the shifts on a normal day, without the use of Bank or Agency staff. In relation to newly recruited members of staff or volunteers the original CRB document must be kept so that a CSCI officer is able to check it during the inspection nearest to the date of recruitment. The manager must ensure that two references with appropriate information about the skills and qualities of the new applicant are received prior to new staff commencing work. The manager must successfully complete the Registered Managers Application with the CSCI. 31/03/06 7 YA37 9(1) 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard YA16 YA17 YA34 YA40 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. The plan to review the menus and to seek the advice of a dietician should go ahead. So that access to information in staff files is made easier the files should be arranged in a more organised way. The Company’s corporate Policies and Procedures should be reviewed, dated and adapted if necessary to fit the service being delivered. Strothers Road DS0000065006.V282216.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Strothers Road DS0000065006.V282216.R01.S.doc Version 5.1 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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