Care Home: Bailiffgate, 16

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

What the care home does well The home is well maintained and is comfortably furnished so that people feel relaxed and settled in their home. Bedrooms are personalised to suit peoples` individual taste and interests. Good systems for record keeping are in place that safeguard people living in the home and staff. Information is securely to ensure that confidentiality is ma maintained.The care plans provide good information for staff about peoples` needs and how these will be met. Changes are updated as they occur and there are good monitoring systems in place. Daily tasks are allocated efficiently which helps staff to make sure everything has been done and that all residents needs have been met. Staff training has exceeded minimum standards and arrangements are in place for regular updating training to take place. Emphasis is placed on ensuring that the training needs of staff members are identified on an individual basis. Residents are involved in all aspects of care planning and attend reviews of their care. There are a good variety of activities available to residents, which means that there is something of interest for everyone to do. What has improved since the last inspection? The sitting room has been redecorated and refurbished so that it provides a comfortable and relaxed area in which to spend time. All the bathrooms have been painted. Staff continue to listen to peoples` views and wishes and try to act upon them to provide a better service. What the care home could do better: A washer with a sluice programme would help to prevent risks of cross infections. The grouting in the bathroom on the ground floor needs to be replaced. CARE HOME ADULTS 18-65 Bailiffgate, 16 16 Bailiffgate Alnwick Northumberland NE66 1LX Lead Inspector Anne Urwin Brown Key Unannounced Inspection 7th July 2008 08:45 Bailiffgate, 16 DS0000000669.V367969.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 Bailiffgate, 16 DS0000000669.V367969.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. Bailiffgate, 16 DS0000000669.V367969.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bailiffgate, 16 Address 16 Bailiffgate Alnwick Northumberland NE66 1LX 01665 605669 01665 605669 bailiffgate@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 Cuthberts Care Mrs Jacqueline Elisabeth Dunn Care Home 11 Category(ies) of Learning disability (11) registration, with number of places Bailiffgate, 16 DS0000000669.V367969.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th June 2007 Brief Description of the Service: Bailiffgate is registered to accommodate eleven people with learning disabilities. It is situated a short walk from the centre of Alnwick near to shops and leisure facilities. There is access to public transport in the town. The accommodation is provided in a stone built terrace house on three floors. There are spacious bedrooms with shared toilet and bathing facilities. There is a kitchen diner and a communal lounge situated on the first floor. There is a large garden to the rear of the building. A lift is installed for access to the first and second floor. Information about the home is available in the statement of purpose and service user guide. The last inspection report is made available. Fees range from £353 and £756. Bailiffgate, 16 DS0000000669.V367969.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating of this service is 3 star. This means that people using this service experience excellent quality outcomes. How the inspection was carried out Before the visit: We looked at: • Information we have received since the last visit on 29th June 2008. • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on 7th July 2008 and seven hours were spent at Bailiffgate. During the visit we: • • • • • • Talked with people who use the service, staff and the manager. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit. We told the manager/provider what we found. What the service does well: The home is well maintained and is comfortably furnished so that people feel relaxed and settled in their home. Bedrooms are personalised to suit peoples’ individual taste and interests. Good systems for record keeping are in place that safeguard people living in the home and staff. Information is securely to ensure that confidentiality is ma maintained. Bailiffgate, 16 DS0000000669.V367969.R01.S.doc Version 5.2 Page 6 The care plans provide good information for staff about peoples’ needs and how these will be met. Changes are updated as they occur and there are good monitoring systems in place. Daily tasks are allocated efficiently which helps staff to make sure everything has been done and that all residents needs have been met. Staff training has exceeded minimum standards and arrangements are in place for regular updating training to take place. Emphasis is placed on ensuring that the training needs of staff members are identified on an individual basis. Residents are involved in all aspects of care planning and attend reviews of their care. There are a good variety of activities available to residents, which means that there is something of interest for everyone to do. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Bailiffgate, 16 DS0000000669.V367969.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 Bailiffgate, 16 DS0000000669.V367969.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): Standard 2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are confident that the service can meet their needs because there are good assessment systems in place at Bailiffgate. EVIDENCE: Considerable time and effort is spent planning to make an admission to Bailiffgate that focuses on the personal needs of the individual. Prospective residents and their families are fully involved and are central in making decisions about how the process of admission is managed. There is emphasis placed on responding to individual needs for information, reassurance and support. A comprehensive needs assessment is undertaken before admission by staff. The home obtains a comprehensive care management assessment and care plan before admission. Individuals are supported and encouraged to take part in the admission process. Information is collected from a range of sources including professionals working with the person and from pre-visits to the service by the individual. Two relatives said that they had been involved in the admission process and were satisfied that they had enough information at the Bailiffgate, 16 DS0000000669.V367969.R01.S.doc Version 5.2 Page 9 time about the service. The manager says that this provides clear information about the person’s present needs, but sometimes it is necessary to request more background information about the person’s history to identify the impact of incidents that have occurred in the past, which may be triggers to particular behaviour. This has happened at the time of the most recent admission. Before agreeing to an admission the service carefully considers the assessment information and the capacity of the home to provide a suitable service. Bailiffgate, 16 DS0000000669.V367969.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): Standards 6, 7, and 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Individuals are involved in decisions about their lives and play an active role in planning the care and support they receive. EVIDENCE: People using the service are encouraged to make decisions about their care and this is reflected in their care plans. Each person has a care plan that is based on a central assessment. The assessment is added to during their placement and the plan is developed with the person concerned. Plans include reference to equality and diversity issues relevant to each person. There is clear information to show the development of plans and peoples’ changing needs. Information about peoples’ health care needs is clearly recorded. Staff have developed different methods to help people using the service to contribute to the care planning process so that their views about their care are Bailiffgate, 16 DS0000000669.V367969.R01.S.doc Version 5.2 Page 11 taken into account and respected. Care plans are up to date and monthly summaries provide a clear overview of what is happening for individuals. There is regular discussion about peoples’ care at staff meetings so that all staff are clear about any work going on with individuals. Copies of reviews were available and these showed that people are assisted to be involved in the process and in planning for the future. Each plan included comprehensive risk assessments that were up to date and clear. The service has a positive view towards risk assessments that focuses on supporting people to live the life they want to lead. Records show that assessments are regularly updated. Any limitations on freedom, choice or facilities are in peoples’ best interests and these are well documented and agreed with the person and/or their representatives. In a questionnaire for relatives one person said “ Bailiffgate staff understand her (my daughter’s) needs very well and give her all the support and care she needs without over protecting her.” People living at Bailiffgate are involved in making decisions about the day to day life in the home and any changes planned. Bailiffgate, 16 DS0000000669.V367969.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): Standards 12, 13, 15, 16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who use the service are able to make choices about their lifestyle, and supported to develop their life skills. Social, educational, cultural and recreational activities meet individual’s expectations. EVIDENCE: At Bailiffgate people are encouraged to live an ordinary, meaningful life appropriate to their preferences in both the home and local community. Staff recognise the importance of enabling people to follow their own interests and to take an active part in life in the local community. Policies and procedures for staff at Bailiffgate take account of the need to respect peoples’ rights and their equality and diversity. People living at the home are able to enjoy full and stimulating lives that suit their preferences and routines. Bailiffgate, 16 DS0000000669.V367969.R01.S.doc Version 5.2 Page 13 Each person has a weekly planner that identifies their activities for the week and staff support them to develop and maintain social, emotional, communication and independent living skills. People are encouraged to access education and work experience that is appropriate to their skills and interests. Outcomes for people are positive and relatives said in the questionnaires that staff support people well. One relative said that daytime activities are well organised. Residents were relaxed and looked happy during the inspection, two people said that there was always plenty to do and staff supported them well. Staff were respectful towards residents and a good rapport existed. Staff said that service users have good links with the local community where they access banks, post office, shops theatre churches, pubs, cafes and college. Peoples’ interest include gardening, craftwork, art, visits to the local sports centre and horse riding. On the day of the inspection some people were shopping, one was gardening, another was going to an appointment and others were spending time in the house. Three people said that they were happy with the activities on offer. Visitors are always welcome at any time and links with family and friends are supported and encouraged. People living in the home are encouraged to help to plan, shop for food and help with preparation of meals. Menus show that meals are well balanced and nutritious and are based on healthy eating principles. Alternatives are available for people so that there is a choice, although individual likes and dislikes are well known to staff. Staff provide assistance to those who have difficulty with feeding. Mealtimes are relaxed and staff were aware of those who needed help and allowed plenty of time for them making the meal a pleasant social event. Particular dietary needs are identified within individual care plans. Residents enjoyed the food served and said it is good and that they can ask for something different if they do not want the food available. Bailiffgate, 16 DS0000000669.V367969.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): Standards 18, 19 and 20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Good arrangements are in place to ensure that the health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Individual plans provide good information about the support provided to each person living at Bailiffgate. Staff demonstrated a good knowledge of peoples’ preferences and personal needs. Support is organised to suit the preferences of each individual for example rising and retiring times, bathing and other activities. Specific staff training has been provided to ensure that staff are able to effectively meet individual needs. Records show that peoples’ health needs are identified and met. All service users are able to access specialist support from healthcare professionals as needed. Evidence was available that peoples’ health care needs are monitored and potential problems identified and treatment sought. This was confirmed Bailiffgate, 16 DS0000000669.V367969.R01.S.doc Version 5.2 Page 15 by a healthcare professional who completed a questionnaire sent out at the time of this inspection. People living in the home are encouraged and supported to attend all health screening and records are kept when this is refused. Staff training in epilepsy, diabetes, basic podiatry and dementia has been provided. Staff provide a good level of personal support to service users in line with their needs and preferences. Levels of support are decided after assessments are carried out and these are reflected within care plans, which are reviewed regularly. Privacy and dignity is respected at all times. The home fully respects the rights of people living at Bailiffgate in the area of healthcare and medication. Staff are alert to changes in mood, behaviour or general well-being and understand how they should respond and take action. There are good procedures and policies in place to protect service users receiving medication. Arrangements for the administration of medicines protect people living in the home. Records are well maintained and arrangements for the storage of medicines are satisfactory. Staff training in administration of medicines has been provided for all staff. Bailiffgate, 16 DS0000000669.V367969.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): Standards 22 and 23 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 are able to express their concerns and access an effective complaints procedure, and are protected from abuse. EVIDENCE: A good complaints procedure is in place that is clearly written and easy to understand. People living in the home are made aware of how to express concerns and encouraged to put forward their views. At every person’s review meeting staff discuss the complaints procedure to ensure that everyone is reminded about how to express concerns or complaints. There have been no complaints since the last inspection. There is a good system in place to ensure any complaints, the investigation and outcome are well recorded. There have been no safeguarding referrals have been made since the last inspection. Clear policies and procedures are in place for safeguarding adults. Staff at the home demonstrated that they are aware of what the procedure is and how to respond. They have received appropriate training and staff records confirm this. Individual risk assessments protect residents from potential selfharm. There is a clear system for staff to report concerns about colleagues and managers. Staff have training in dealing with verbal and physical aggression and there are written procedures for dealing with this. Evidence was available Bailiffgate, 16 DS0000000669.V367969.R01.S.doc Version 5.2 Page 17 about how this is dealt with was available from records and this showed good systems in place that are regularly reviewed to take account of changing needs. There was evidence that the home regularly seeks advice from healthcare professionals for any specific behaviour plans. Bailiffgate, 16 DS0000000669.V367969.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): Standards 24, 25 and 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home provides a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: The home is a large terraced house in Alnwick, close to the town centre. There are three floors and the home is domestic in style. A shaft lift is fitted to provide access to the first and second floors. Bedrooms are personalised, comfortable and homely. In one bedroom a wardrobe was not secured to the wall and seemed unsteady. The communal lounge is upstairs has been redecorated and refurbished with a new carpet and sofas. This provides a comfortable and relaxing environment. Comments were made about the lack of a sitting area on the ground floor, which is at times a disadvantage for those people with bedrooms downstairs. Bailiffgate, 16 DS0000000669.V367969.R01.S.doc Version 5.2 Page 19 Furnishings and décor have been chosen to promote a homely, comfortable and safe environment, adhering to fire and safety regulations. People living in the home are involved in making choices about the décor. An annual programme identifying redecoration priorities is in place. Systems are in place for ensuring maintenance is carried out without delay. The kitchen is well fitted and is where residents and staff tend to congregate over a cup of tea. There are two large tables in the kitchen and staff and residents take meals together. There was a relaxed atmosphere in the home during the inspection. There is a large garden area that is available for residents to use. It is quite private and secure. The home is clean and hygienic. The bathrooms have been painted since the last inspection, although the grouting around the tiles in the ground floor bathroom is marked and discoloured. There are no offensive odours. Bathing facilities provide privacy and meet service user’s individual needs. Infection control procedures are in place and a small laundry area is available at the rear of the building. There is a washing machine that does not have a sluice facility and no other sluice is available. Space is very limited in the laundry. A cleaning programme is in place to ensure the home maintains a safe, clean environment. A domestic is employed at Bailiffgate to carry out cleaning duties and is assisted by staff in this task. Some people living at Bailiffgate are also involved in cleaning tasks around the home to promote independent living skills. Bailiffgate, 16 DS0000000669.V367969.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): Standards 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient trained and effective staff meet the needs of people living in the home. Good recruitment practices safeguard people at Bailiffgate. EVIDENCE: Staff is generally sufficient to meet the needs of the people living at Bailiffgate, but additional resources have been needed recently to support one person who has dementia. The manager says that this person can be supported in the short term, by one to one staffing that has been achieved by staff working additional hours. Records show that individual support is provided to ensure peoples’ needs aspirations and activities are met. People living in the home said that they feel well supported by staff and that there are enough staff to meet their needs. Staff demonstrate a very good rapport with residents. The culture in the home is very positive and staff said they enjoy working there. There is a good atmosphere in the home and residents appear well cared for with their Bailiffgate, 16 DS0000000669.V367969.R01.S.doc Version 5.2 Page 21 individual needs met. One relative said in the questionnaire “All the care staff are dedicated and work well as a team. They really care about the well being of the residents.” Another said “All the staff are very professional, but also give loving care to all in the home.” Residents said that they liked the staff and could talk to them. Good recruitment procedures are in place and are followed. Staff records contained appropriate information. This included two references and criminal records checks. A comprehensive induction takes place for all new staff that includes reference to equality and diversity issues. Staff said that new staff members are well supported and they given enough information about the service and the people living there to be able to help them understand their role and responsibilities. A good range of policies and procedures are available to guide staff. These are regularly reviewed and updated. There is evidence that the service keeps up to date with changes in practice and legislation. Records show that staff have appropriate training opportunities to help them with their work. All have received mandatory training. All staff have their own training portfolio containing certificates from training attended. All staff have completed national qualifications in care at a level above the minimum standards. Training has been provided in infection control, health and safety, first aid, moving and handling, protection of vulnerable adults, foot care, and medication administration. Staff said that they get plenty of training opportunities. Bailiffgate, 16 DS0000000669.V367969.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): Standards 37, 39 and 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is well organised and takes account of the views of people living in the home. Good quality systems and health and safety practice have been developed to provide good outcomes for the people at Bailiffgate. EVIDENCE: The registered manager has the required qualifications and experience to run the home and meet its stated aims and objectives. The manager is recently appointed and is having appropriate training and support to ensure that she has a good knowledge of the organisation’s strategic and financial planning systems. She says that she is well supported by the senior management of Bailiffgate, 16 DS0000000669.V367969.R01.S.doc Version 5.2 Page 23 the organisation. She communicates a clear sense of direction and has a good understanding of the need for continuous improvement, customer satisfaction and quality assurance. She understands the importance of equality and diversity and person centred planning in planning the service’s development. There is a good system of quality assurance in place that takes account of the views of people living in the home. It was apparent that people living in the home and the staff feel able to put forward their views and the current resident meetings are to be developed to encourage people to contribute more effectively. Relatives’ questionnaires are used as part of the quality assurance process. There are effective systems in place to ensure that there are good records of any money held on behalf of people living in the home. All transactions are recorded individually and money checked during the inspection balanced with the individual records. People living in the home are supported to manage their own money where possible. Those who don’t have the skills are encouraged to take as much responsibility as it is safe to do. All working practices are regularly reviewed. Good systems are in place for checking on health and safety in Bailiffgate. Records are kept in good order for these checks. Appropriate training is provided for staff and regularly updated. Risk assessments for the premises and for fire are in place. Fire alarm tests are carried out weekly and records were available to confirm this. Accident records are kept in an appropriate form. Bailiffgate, 16 DS0000000669.V367969.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 4 X 4 X X 3 X Bailiffgate, 16 DS0000000669.V367969.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA30 YA24 Good Practice Recommendations A washer with a sluice programme would provide protection against possible cross infection. The grouting in the ground floor bathroom is marked and needs to be replaced. Bailiffgate, 16 DS0000000669.V367969.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Bailiffgate, 16 DS0000000669.V367969.R01.S.doc Version 5.2 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!