Inspection on 25/06/07 for Wingrove Road

This inspection was carried out on 25th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wingrove Road 04/01/06

Wingrove Road 31/08/05

Wingrove Road 08/11/04

Wingrove Road 14/06/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Wingrove Road 182 Wingrove Road Newcastle Upon Tyne Tyne & Wear NE4 9DB Lead Inspector Carole McKay Key Unannounced Inspection 25 and 26th June 2007 09:30 th Wingrove Road DS0000000464.V338089.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 Wingrove Road DS0000000464.V338089.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. Wingrove Road DS0000000464.V338089.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wingrove Road Address 182 Wingrove Road Newcastle Upon Tyne Tyne & Wear NE4 9DB 0191 2738861 NO FAX wingrove@stcuthbertscare.org.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (If applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) St Cuthbert’s Care Ann McDonald Davison Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Wingrove Road DS0000000464.V338089.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th January 2006 Brief Description of the Service: 182 Wingrove Road is a residential care home providing personal care and accommodation for 8 female service users with learning disabilities. Four of these people are over 70 years of age. The home is in a residential area close to local amenities. The home is on three floors and there is a passenger lift to all levels. There is a variety of aids and adaptations around the building to allow service users to move around more independently. All bedrooms are single, one has an en-suite facility. Since the last inspection a new manager has been appointed. This is the third manager the home has had in recent years. The manager is registered with The Commission for Social Care Inspection and has been in post for approximately six months. Her name is Ann McDonald. The fees for the service range from £506.11 to £624.62. Wingrove Road DS0000000464.V338089.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The manager of the service completed and returned information before the service was visited. This was used in planning the inspection and shaping the visits to the home. The home was visited on two occasions so that all of the service users could have some input into the inspection process. It also gave an opportunity to meet with the new manager to discuss plans for the future. Two of the staff participated in the inspection. The care records of three of the service users were examined as well as other more general records and procedures. What the service does well: What has improved since the last inspection? The service has introduced a way of checking the quality of the service. This means that the people living at the home will continue to benefit from living there. More community based opportunities have been identified for people who use the service. This means that people are using local facilities with greater independence. The way medication is handled has improved so that there is less risk of mistakes and people are safe from harm. Wingrove Road DS0000000464.V338089.R01.S.doc Version 5.2 Page 6 The complaints procedure has been revised so that service users can understand and use it more easily. Health and safety guidance, safety checks and risk assessments have been developed further so that service users are supported to be independent in a safe environment. 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. Wingrove Road DS0000000464.V338089.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 Wingrove Road DS0000000464.V338089.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): 1,2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People visiting the service will be given information about how the service meets people’s needs, but it may not be up to date or easy for people to understand. It will not reflect how well the service can meet the needs of all ages. People who move to the service will have their needs assessed but if they are older some of their future health needs may not be considered in the initial assessment. EVIDENCE: At the last inspection the service was required to update the Statement of Purpose, and information available to service users and other people who may be considering coming to live at 182 Wingrove Road. This was so that the information was easier to read and understand. This has not been done. But the new manager has stated in writing that she is aware that this is outstanding and has given a commitment to finishing this piece of work. No person has been admitted to the home since 2005. Seven of the service users have lived at this address for at least seven years and some have lived here much longer. Although the service is being inspected against the standards for younger adults, four of the people who use the service are now over the age of 65. Wingrove Road DS0000000464.V338089.R01.S.doc Version 5.2 Page 9 This means that the needs of some of the people living at the home are changing, or could change suddenly and will change as time goes by. The Statement of Purpose does not take this into account. So other people who may want to use the service cannot see how well suited the home is in meeting the needs of older people as well as younger adults. Service users care records contain comprehensive assessments. These are particularly well suited to the needs of the younger people who use the service and cover most of the needs of older people living at the home. But they could be improved by including some age related assessment tools so that the ageing process is taken into account. This will ensure that the health and safety for all service users continues to be promoted, as people get older. The manager said that St Cuthbert’s Care is introducing a new assessment process for all service users. Wingrove Road DS0000000464.V338089.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): 6,7and9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service will have a plan of care. They will be involved in making these. Their independence will be promoted through risk assessment. The service is adapting the way it supports people to be independent. This will make sure that people continue to have their needs and choices met into older age. EVIDENCE: Service users each have a plan of care, called a service user plan. These describe the person’s needs and how these will be met. The records show how people who use the service have been involved in producing these. Some of the service users have lived at the home for several years and in this time they have gone from being in their sixties to their late seventies. At this time this is not presenting any difficulty for them or for the service. It is not clear how the service is preparing to adapt, so that people can continue to live at the home for as long as they are able and wish to do so. Wingrove Road DS0000000464.V338089.R01.S.doc Version 5.2 Page 11 The manager said that St Cuthbert’s Care has produced a new style of service user plan and she will be using these with people who live at the home in the future. The service user plans are reviewed. These reviews do not take into account how the service can or needs to adapt to the changing needs of service users. The manager has begun to do this by considering the safety aspects of having accommodation on three floors. Also the manger has started to consider how the varied activity levels of service users can be best promoted so that they can continue to enjoy as much independence as possible, for as long as they choose to do so. But the manger said that she has more work to do on this. The plans include the personal goals of the service users. Risk assessments are carried out. These ensure the safety of service users in following the plan of care and achieving personal goals. For example two service users go to the bank unaccompanied. This has been risk assessed and planned for, and is recorded in the plan of care. Daily records are written. These describe how each person has spent their day and show that people who use the service are encouraged to lead an independent life and make their own decisions. During the visit to the service staff were observed to encourage the people who live at the home to make choices about food and where they spent their time. Outings and holidays were being planned with service users. Wingrove Road DS0000000464.V338089.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live at the home are encouraged to form relationships and be part of the community. The manager has identified that the service needs to adapt so that service users do not become isolated by way of old age or disability. Menus have been revised. This means that the people living at the home can choose what they eat and can have a healthy diet. The service does not assess dietary needs so that older residents continue to eat well. EVIDENCE: The service users are all between the ages of 53 and 79. Some people cannot get about very well or walk very far. Others cannot see very well. All service users can communicate their needs and preferences. Some people like company more than others. This means that their social needs are very varied. Wingrove Road DS0000000464.V338089.R01.S.doc Version 5.2 Page 13 To address this the service encourages each person to have an individual plan of activity and personal hobbies. The preferences of each person are recorded and so are the things they like to do, the places they go and the people who are important to them. Some of the women living at the home attend church and church groups with people of their own age. Individual friendships are encouraged. For example one service user has a long standing relationship with a male friend and the staff help her with visits to and from this person. The manager said that she has identified some of the ways that the service could do more to support some people to get out and about. The manager has ideas that will help promote activity for people who are more dependent. She is looking into some therapeutic activity for one person who cannot see very well. The manager and staff said that the menus had recently been revised to take account of healthy eating. The service user were involved in this. A dietician has not seen the menus, but they appear well balanced and the food on the day of the visit was wholesome with a choice of main course. Service users choices are respected to do with what they eat, when and where they eat. This was observed. The service does not have a nutritional risk assessment that takes account of special needs and the ageing process. This could be useful for some of the people who live at the home and promote continued good health. Wingrove Road DS0000000464.V338089.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service user will have their health care needs assessed so that they stay well. The way that the home assesses health needs does not take full account of ageing and consent. Routine health care is supported well. The use of medication is managed in the interests of the safety and the independence of the people who use the service. EVIDENCE: Each service user has an assessment of needs and a plan of care. Most of the people who live at the service are almost fully independent in their personal care. They rely on staff for reminders and guidance only. Where service users do need support this is clearly described in the service user plan. For example, there is a detailed plan for assisting one of the service users to take a bath. But there is a lack of information to do with how service users prefer to be supported, their capacity to consent and their choices. The assessment process is designed very well for people who are younger adults but there are no specific age-related assessment tools. For example, Wingrove Road DS0000000464.V338089.R01.S.doc Version 5.2 Page 15 there is no falls risk assessment and no nutritional risk assessment. These, and others, could become very useful in the future for identifying health risks for people who use the service, as they get older. One of the people who use the service is prone to falls. Routine health checks are arranged for the people who use the service and they are supported to attend these. These are recorded in service user plans. Health problems are clearly described in service users’ plans. For example in one of the files the effects of a person’s sight problem are described, so that staff can appreciate how best to support the person. There is evidence that staff have signed forms for the GP practice on behalf of service users. This was to do with not taking up routine screening. The error was corrected by the practice. Staff need to be clear in their understanding of who can and cannot consent to treatment, so that the rights of service users are preserved. Anne, the manager of the service, demonstrates an understanding of the emotional impact the ageing process could have on the people who use the service. Anne described some of her planning to address future needs. These include staff training. There are medication policies and procedures in place at the service. These are the procedures of St Cuthbert’s Care and were discussed with Anne. Anne has identified that these need to be revised to fit more closely with the needs of the service and the service users. The system of medication administration has changed since the last inspection so that storage arrangements are improved. Anne said that the new system works well. The storage and records of administration are satisfactory. Risk assessments are carried out to support people to take control of their own medication. Three service users control some or all of their medications at the present time. Risk assessments are reviewed at meetings between service user and their key workers. These take place every three months. Consent to treatment forms are included in the service users’ plans, but some of these are not signed. Wingrove Road DS0000000464.V338089.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service provides people who use it with the information they need to raise concerns. Service users are confident about doing this. A central record of complaints is not kept. The service strives to protect people from harm. The local external procedures for safeguarding are not readily available to staff. EVIDENCE: The service has a complaints procedure that is written in a way to help service user understand the contents. Each service user has a copy. The manager said that the procedure is also discussed at every service user meeting so that people who may not be able to see or fully understand the written procedure receive the information verbally. Service users who were asked about this said that they understood what to do if they were unhappy about anything and they said that staff would listen to them. In particular, service users mentioned their key workers as people who they would talk to. Complaints that are made are recorded in the service user files, but the service does not hold a central record of complaints received. One complaint has occurred since the last inspection. This was to do with staffing arrangements and was resolved prior to the current manager coming into post. There are no outstanding complaints. Anne has identified that more Wingrove Road DS0000000464.V338089.R01.S.doc Version 5.2 Page 17 focus needs to be given on concerns and complaints during service user meetings and this is part of her plan for the next twelve months. Staff have received training in the procedures for protecting vulnerable adults. The service has a written policy and procedures for staff to follow if they have concerns, so that they know how to raise them. The staff said that they had seen copies of the procedures that the local authority in the area follows for protection of vulnerable adults, but these could not be located. The manager said that she would find these and make sure that staff had read and understood these. The service has a process for assessing risk. Risk assessments are completed in service user plans. The procedures for supporting service users with money and finance make sure that staff have to account for all transactions they are involved with. Some service users are able to manage these things independently. This is encouraged and supported by good risk assessment and management plans. Wingrove Road DS0000000464.V338089.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a safe and comfortable home and they like living here. They are able to personalise their own space. The service has provided some adaptations. Plans have yet to be made for service users’ future needs, so that people can continue to live at the home as long as possible. EVIDENCE: The manger has begun to identify how the service will need to adapt to the needs of older people. For example by reviewing with the fire officer the use of the second floor. This is a good start to reviewing the premises from the point of view of older person’s needs and more should be carried out. Some adaptations are already in place. There is an assisted bath and the home has a shaft lift for access to the upper floors. It is very comfortably furnished, pleasant and airy. The bedrooms that were examined were all individually furnished and decorated. Service users said that they were happy with their Wingrove Road DS0000000464.V338089.R01.S.doc Version 5.2 Page 19 rooms and had enough furniture and storage. Each room was personalised by the belongings of each service user. The service is located on a main bus route and gives easy access to the city centre. Externally the gardens are not ideally suited for sitting out as the home is on a corner site, beside a busy main road. But the manager has arranged for some repair work in the small yard to the rear of the house to be carried out. After this is finished Anne plans to improve this area and to provide seating. Inside the home Anne has identified areas for improvement in the next 12 months. The bathroom is to be upgraded as part of the plan. The hoist in the bathroom was not working and a service engineer had been called out to make the repair. There is a regular maintenance check carried out and a cleaning schedule. The effects of these are that the home is clean and well presented. Risk assessments for the premises are carried out. Safety checks for fire, electrical appliances and lifting aids have been carried out. The home has a separate laundry room. This is spacious and properly equipped. The guidelines for food safety and infection control are openly available for staff to follow. Wingrove Road DS0000000464.V338089.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient staff are employed to care for the service users living at the home. Staff are recruited in a way that protects service users from harm, but some earlier recruitment practices are not appropriate. Staff are trained properly to carry out their basic duties and to care for service users safely. A long- term staff training plan has not been devised. EVIDENCE: The service has one staff vacancy. This has been managed. The replacement person has been recruited and will start once all the required checks have been undertaken. Staff cover on the rota shows that the agreed staff level is being provided. This is one staff member at night and two working through the day. The manager provides some of this cover as well as call out cover. New staff go through a programme of introductory training with St Cuthbert’s Care. This covers training in safety that staff must have and the organisations’ policies, procedures and practices. The new staff also go through training that meets national training standards. A workbook for the initial training is used and one of these was examined at this inspection. Wingrove Road DS0000000464.V338089.R01.S.doc Version 5.2 Page 21 The manager said that one of the service users took part in the interviews for the new member of staff. The service user confirmed this and said that she enjoyed asking questions. The recruitment process is managed by a section of the organisations’ head office. Staff files are also kept at the home. Four of these were examined. These show that people who apply to work at the home have to fill in an application form. Two written references are asked for. In one of the files the previous manager of the service had given a reference for one of the staff she had recruited. Checks for criminal records had been carried out, but these were not available in the files. The reference numbers of each check were recorded in three files. In the file of a more recent employee the details were also recorded. The files show that new staff have to work for a trial period and the manager checks their work at the end of the period. Anne said that staff meet with her in one to one meetings. The files have these meetings recorded in them. These are used to identify the training needs of staff. Anne said that St Cuthbert’s Care offers staff further training. All staff undertake a National Vocational Qualification (NVQ). The files contain these certificates. Staff also have opportunities through St Cuthbert’s Care to do special training. For example the files show that some staff have had training in communication skills and the effects of stroke. The manager said that she plans to develop staff training over the next twelve months, but she has not had time yet to carry out a training needs assessment for the staff team as a whole yet. Wingrove Road DS0000000464.V338089.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager of the home is confident and has identified areas for improvement in the service. This means that the people living at the home will experience an improving service that changes as their own needs change. Internal quality checks are in place to make sure that the people living at the service are safe and are having their needs met. EVIDENCE: Anne has managed the service since the beginning of the year and has recently successfully registered with the Commission for Social Care Inspection (CSCI). She has experience of working in other services for people with learning disability and is properly qualified. Wingrove Road DS0000000464.V338089.R01.S.doc Version 5.2 Page 23 She has a lot of experience in managing risk to support people with their independence and making choices. Ann said that she wants to promote this at the service. There is evidence that this has already started. Guidance documents for staff have been made available along with daily checks to make sure that the home is safe at all times. A yearly development plan has been written. The views of service users and their families have been taken into account, but the service could do more to attract the views of other people who know the service, for example people who have contact with the home but are independent, such as advocates and health workers. Since becoming the manager of the home Ann has made sure that risks are reduced and that health and safety checks are carried out. She has identified where the service needs to have improvements made and has identified risk areas. Ann has taken action to involve other agencies such as the fire officer and is updating safety procedures. Wingrove Road DS0000000464.V338089.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 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 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 3 X X 3 X Wingrove Road DS0000000464.V338089.R01.S.doc Version 5.2 Page 25 Yes 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 YA1 Regulation 4 Requirement The homes statement of purpose, to be reviewed and updated and produced in a userfriendly format including video or audiotape. Outstanding. The review must include the service aims and objectives, staffing provision and premises to take account of the age of the service users. 2 YA2 YA17 YA19 14 Assessment tools that address the needs of older people to be used alongside the home’s assessment, for falls, pressure sore risk, nutrition. The choices and preferences of service users to do with their personal care to be included in the assessments Guidance to do with good nutrition for older people to be available to the staff. Copies of the local safeguarding adults procedures to be available to staff at all times so that they can refer to these in the event of an incident. The manager to make sure staff understand DS0000000464.V338089.R01.S.doc Timescale for action 01/09/07 31/10/07 3 4 YA17 YA23 12 12 31/10/07 01/09/07 Wingrove Road Version 5.2 Page 26 these. 5 YA34 19 Schedule 2 CRB certificates must be 31/10/07 available for inspection. Or where an umbrella organisation or corporate body is used the minimum expectation is that on receipt of the disclosure the following information recorded in a letter from the body carrying out the CRB check should be issued to providers: • The name of the person; • Date of disclosure; • Level of disclosure; • Including poca check (if requested ); • Including pova check (if requested ); • Disclosure reference number; • Date pova first check received ( if this was sought); and pova first reference number. Letters must be kept on file and be available for inspection at the home. Staff to receive training to do 31/10/07 with the capacity of service users consent to treatment. Staff to receive training in the 31/10/07 ageing process, illness and palliative care. The manager to develop a stafftraining programme, which will fulfil the aims of the home and meet the changing needs of service users. 31/12/07 6 7 YA35 YA35 18 18 8 YA35 18 Wingrove Road DS0000000464.V338089.R01.S.doc Version 5.2 Page 27 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 YA22 YA34 Good Practice Recommendations A separate record of concerns and complaints to be maintained References for applicants should be taken from people who are independent of the service. Wingrove Road DS0000000464.V338089.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Text phone: 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 Wingrove Road DS0000000464.V338089.R01.S.doc Version 5.2 Page 29 - 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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