Care Home: Belgrave Terrace

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What the care home does well The care plans make sure that people are given opportunities to take risks, which is important as part of living an independent lifestyle. Social care plans are being developed so that people`s wishes can be achieved. People are helped to access all health care and Advocacy services. Visitors are always welcomed and there are links with the local community. Staff are respectful and sensitive with people when helping them or when speaking to them. The activities available to people are tailored to individuals requirements and staff work hard to provide a range of social activities. The menus offer a variety of well-cooked nutritious meals. People can enjoy a healthy, well-balanced and interesting diet. Clear information is available should anyone have a concern or complaint about the care or service they are receiving. The registered manager makes sure that all checks and clearances are received before staff are employed. Staff are trained well so that they understand the needs and behaviours of people, which in turn promotes their well-being. There are good arrangements for supporting people to keep their personal monies in a safe place if they want. The views of people in the home and their representatives are sought so that the manager and staff can continue to develop the service. There are good daily, weekly and monthly checks in place to make sure the home is safe and well maintained. Three people who use the service returned surveys. They said: "I was told about the home before I moved in". "I came for a visit before I moved in". "I can make my own decisions." "I like to be independent." "I can please myself what I do." "I am happy." "The home is clean and tidy." "The food is good and I choose what I want to eat." Staff said: "I learnt a lot from the introduction as I had never worked in care before and still use the information". I have now completed my National\Vocational Qualifications level 2 and other training." "We give residents a good quality of life. I have worked here for many years and never had a complaint." What has improved since the last inspection? This is a newly registered service which has changed owners. What the care home could do better: The Service User Guide and Statement of Purpose should be available in different ways to help people make a decision about using the service. People living in the home need to have a detailed contract that they can understand and sign. Menus should be in a style that people can easily understand. It would be good if, as well as written information; pictures and symbols were used to help people with communication needs make decisions and choices. Medicines need to be stored according to the requirements from the Royal Pharmaceutical Society. The basement flat needs to be refurbished and natural lighting provided. A planned maintenance and renewal programme for the fabric and decoration of the building is needed. All radiators need to have suitable guards and low surface temperatures. The recruitment of staff needs to continue. There needs to be up to date policies and procedures which both staff and people living in the home have access to.Comments from staff included: "Could have extra staff for holidays and going out" "As people are getting older it would help if we could have more support when people are going out". "We presently are short staffed". One person has complained that the promised changes to the basement flat have not happened. CARE HOME ADULTS 18-65 Belgrave Terrace 2 Belgrave Terrace South Shields Tyne and Wear NE33 3RY Lead Inspector Irene Bowater Key Unannounced Inspection 1st September 2008 10:00 Belgrave Terrace DS0000071699.V371492.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 Belgrave Terrace DS0000071699.V371492.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. Belgrave Terrace DS0000071699.V371492.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Belgrave Terrace Address 2 Belgrave Terrace South Shields Tyne and Wear NE33 3RY 0191 4553333 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) Potensial Limited Joy Carron Kerr Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Belgrave Terrace DS0000071699.V371492.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC; To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: 2. Learning disability - Code LD, maximum number of places 8 The maximum number of service users who can be accommodated is: 8 New service Date of last inspection Brief Description of the Service: Belgrave Terrace provides ordinary housing for eight people who have a learning disability. The home is registered to provide personal care. Nursing care cannot be provided but district-nursing services can be used as required. The home is a large terraced house and comprises of eight single bedrooms, two of which are located in a self-contained basement flat. There is a large lounge, offering a choice of sitting arrangements, and a dining room, which is attached to the kitchen. There is a bathroom, shower, toilets and bedrooms on the first and second floor. The first and second floor can be reached only via a flight of stairs the home would not be suitable for people who use a wheelchair or have mobility problems. The self-contained basement flat consists of two bedrooms, lounge, kitchen, bathroom and toilet. Only the lounge has natural lighting. There is an external entrance and access to the main house is via a steep flight of stairs. The home is situated near to the town centre of South Shields close to a number of local amenities such as shops, public houses and places of worship and is within walking distance of the beach. Fee rates are £466 per week. Belgrave Terrace DS0000071699.V371492.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means that the people who use this service experience good quality outcomes. Before the visit: We looked at: • Information we have received since the home was re reregistered as a new service in March 2008. • How the service dealt with any complaints and 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 and their relatives, staff and other professionals. • • We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations – but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken.” • The Visit: An unannounced visit was made on 1 September 2008. During the visit we: • • • • • Talked with people who use the service, relatives, staff, the manager and visitors. Looked at information about the people who use the service and how well their needs are met. Looked at other records which must be kept Checked that staff had the knowledge, skills and training to meet the needs of the people they care for Looked around the building to make sure it was clean, safe and comfortable We told the manager what we found. Belgrave Terrace DS0000071699.V371492.R01.S.doc Version 5.2 Page 6 What the service does well: The care plans make sure that people are given opportunities to take risks, which is important as part of living an independent lifestyle. Social care plans are being developed so that people’s wishes can be achieved. People are helped to access all health care and Advocacy services. Visitors are always welcomed and there are links with the local community. Staff are respectful and sensitive with people when helping them or when speaking to them. The activities available to people are tailored to individuals requirements and staff work hard to provide a range of social activities. The menus offer a variety of well-cooked nutritious meals. People can enjoy a healthy, well-balanced and interesting diet. Clear information is available should anyone have a concern or complaint about the care or service they are receiving. The registered manager makes sure that all checks and clearances are received before staff are employed. Staff are trained well so that they understand the needs and behaviours of people, which in turn promotes their well-being. There are good arrangements for supporting people to keep their personal monies in a safe place if they want. The views of people in the home and their representatives are sought so that the manager and staff can continue to develop the service. There are good daily, weekly and monthly checks in place to make sure the home is safe and well maintained. Three people who use the service returned surveys. They said: “I was told about the home before I moved in”. “I came for a visit before I moved in”. “I can make my own decisions.” “I like to be independent.” “I can please myself what I do.” Belgrave Terrace DS0000071699.V371492.R01.S.doc Version 5.2 Page 7 “I am happy.” “The home is clean and tidy.” “The food is good and I choose what I want to eat.” Staff said: “I learnt a lot from the introduction as I had never worked in care before and still use the information”. I have now completed my National\Vocational Qualifications level 2 and other training.” “We give residents a good quality of life. I have worked here for many years and never had a complaint.” What has improved since the last inspection? What they could do better: The Service User Guide and Statement of Purpose should be available in different ways to help people make a decision about using the service. People living in the home need to have a detailed contract that they can understand and sign. Menus should be in a style that people can easily understand. It would be good if, as well as written information; pictures and symbols were used to help people with communication needs make decisions and choices. Medicines need to be stored according to the requirements from the Royal Pharmaceutical Society. The basement flat needs to be refurbished and natural lighting provided. A planned maintenance and renewal programme for the fabric and decoration of the building is needed. All radiators need to have suitable guards and low surface temperatures. The recruitment of staff needs to continue. There needs to be up to date policies and procedures which both staff and people living in the home have access to. Belgrave Terrace DS0000071699.V371492.R01.S.doc Version 5.2 Page 8 Comments from staff included: “Could have extra staff for holidays and going out” “As people are getting older it would help if we could have more support when people are going out”. “We presently are short staffed”. One person has complained that the promised changes to the basement flat have not happened. 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. Belgrave Terrace DS0000071699.V371492.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Belgrave Terrace DS0000071699.V371492.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although good assessments of need are made before moving into the home, people are not given enough information to help them make an informed choice about moving in. EVIDENCE: The home changed ownership in March 2008 and the Statement of Purpose (S.O.P) and Service User Guide (S.U.G) are still being developed. There is a S.U.G in the home but it refers to the Care Standards Wales. It is not in plain English, large print, video or picture style and refers to “O’Brien’s five service accomplishments and Wolfensburger’s four main principles”. People who use the service and others would not understand these references. There has been one new admission to the home. There is a Care Managers assessment and the home manager also completes a full assessment before anyone moves into the home. Belgrave Terrace DS0000071699.V371492.R01.S.doc Version 5.2 Page 11 Before moving in people are given the opportunity of spending time in the home getting to know the routines and others who live there. The views of the current people living in the home are also sought before agreement is given for an admission to take place. The contracts currently relate to the previous owners and new ones need to be developed and given to the people living in the home. The contract also needs to be in a style that individuals can understand. Belgrave Terrace DS0000071699.V371492.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Opportunities to take part in life risks and choose how to make major decisions are well managed. This means people are actively involved in their chosen lifestyle. EVIDENCE: Care plans provide staff with clear, detailed guidance on the action they need to take to meet individuals assessed needs. There is also information about those situations that cause people to become agitated and what staff should do to support them when this happens. Each care plan includes risk assessments which are individualised and decisions are agreed with individuals. Belgrave Terrace DS0000071699.V371492.R01.S.doc Version 5.2 Page 13 The home has introduced a “Listen to me” workbook which detail likes, dislikes and goals. For example, one person likes knitting and watching television whilst another likes photography and keeping the photographs in an album. Care plans are detailed about how people’s personal goals and aspirations are going to be met but they do not use many symbols or pictures. The use of these would help increase communication and make sure people can make decisions and choices for themselves. The care plan is a working document which is reviewed six monthly with the person, their family the multidisciplinary team and the manager. There are regular meetings where people are encouraged to be involved in some decision making about the home, such as where to go for their holiday. Advocates have also been contacted to help individuals in the decision making process. Belgrave Terrace DS0000071699.V371492.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Opportunities to take part in meaningful activities and keep control of everyday decisions are good, and mealtimes are organised. This makes sure people can lead full and active lives. EVIDENCE: The staff continue to work with individuals to develop their own goals and life styles. The home has provided television, DVD and video equipment and various board games. They also have their own transport. Care plans show that people go out on an individual and group basis. For example if it is someone’s birthday they can all go out to a restaurant for a Belgrave Terrace DS0000071699.V371492.R01.S.doc Version 5.2 Page 15 meal, others like going out on an individual basis or with a member of staff shopping. Individuals set their goals and these are then reviewed with staff to see if they have been achieved. For example, one person wanted to go for a curry, take photographs and then keep them in an album another wanted to go shopping and out for lunch. Once the goals have been met others are discussed and set. Others do not want to have any goals set due to their age and health. Staff respects these wishes. Friends and family are always welcomed and should anyone develop personal relationships information and specialist guidance is provided to support them. Some people have been to Blackpool on holiday and a further visit has been arranged for September 2008. People have free access to all areas of the home. Some choose to lock their bedroom doors and others prefer to leave doors open so that they can get in and out easily. The people living in the home are getting older and do not really get involved in the domestic routines in the home. One person still likes to make sure her room is clean and tidy and others may help with washing up after meals. In general it is the staff who carry out domestic, cooking, laundry and shopping tasks in the home. There is a four-week menu, which offers choice and alternatives for each meal. Those living in the “basement flat” have a small kitchen area where they can prepare light breakfasts and snacks. They would have their main evening meal with the other people living in the home. Kitchen cupboards, fridge and freezer were full of a variety of foods and at lunch time staff asked what people wanted and a light meal prepared. Hot and cold drinks and snacks were freely available. It would be helpful if the menus were more accessible and in large print and picture style. Belgrave Terrace DS0000071699.V371492.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Access to health care is good and care planning demonstrates that peoples’ needs are being fully met. EVIDENCE: The care plans are person centred and give a detailed view of individuals’ health care needs. The areas covered within the care plans include bathing, mobility, general health and continence needs. Information is available to show how staff support someone who refuses food and may be at risk. For example the care plan details guidelines about daily food and fluid intake and to make sure weights are checked weekly. Another plan details how staff are to support someone with dementia and another shows how someone who may become aggressive is supported. Belgrave Terrace DS0000071699.V371492.R01.S.doc Version 5.2 Page 17 The staff who were spoken to have a good insight into problems and operate an individual, and person-centred approach, to caring for them. Everyone has regular access to their GP and other medical professionals, such as opticians, dentists, occupational therapists, speech therapists and consultant psychiatrists. Medicines are kept in a safe and secure location and the Medication Administration Records (M.A.R.) showed no discrepancies. Records are kept of all medicines ordered, received administered and disposed of in the home. Staff who administer medicines have been appropriately trained. The Company need to review the current storage to make sure it meets the requirements of the Royal Pharmaceutical Society. The Company have not yet issued their own policies and procedures for the safe administration of medicines. Belgrave Terrace DS0000071699.V371492.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints and safeguarding issues are well managed at home level and protect people from harm. EVIDENCE: There is a complaints procedure, which is readily available on the notice board in the kitchen. It is in a picture format to help people with communication needs to understand it. It is not clear if these procedures relate to the new company and they need to introduce their policy and procedures so that everyone is clear and understands any changes. There has been one complaint made since March 2008.This came from a person living in the home and is about the lack of planned refurbishment to the basement flat. The manager understands the procedures for safeguarding adults and ensures that appropriate referrals are made. She always attends meetings and provides information to external agencies. Belgrave Terrace DS0000071699.V371492.R01.S.doc Version 5.2 Page 19 Again the procedures being followed relate to the previous owners and the new policies need to be introduced and made clear to the staff team. The Local Authority is currently investigating one safeguarding alert. This has resulted in a waking night staff as well as the usual sleep in staff until an assessment of one person’s changing needs can be completed. Personal money is stored securely and detailed records of expenditure incurred maintained. Receipts are obtained for all purchases. Belgrave Terrace DS0000071699.V371492.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27,30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is clean and comfortable but investment is needed to create a pleasing comfortable, safe place for people to live. EVIDENCE: On the day of the visit the home was clean, warm and comfortable. The lounge, dining area and kitchen would benefit from being redecorated. These areas are situated on the ground floor. All of the bedrooms are now for single occupancy. Some people have a key to their room and all have been encouraged to personalise these areas and choose their own decoration. Belgrave Terrace DS0000071699.V371492.R01.S.doc Version 5.2 Page 21 Two bedrooms are located on the second floor of the home, and these are reached by a steep flight of stairs. Lighting has been improved and risk assessments are in place. The bathroom and shower room on the first floor have been refurbished and suitable for peoples needs. Some of these areas do not have accessible handwash facilities which are an infection control risk. Radiators are unguarded and do not have a guaranteed safe low surface temperature. This work needs to be done as some of the people may be at risk of falling and burning themselves. There is a basement flat, which is shared by two people. There is a separate entrance and another exit to the home via a steep flight of stairs. Lighting has been improved in this area. The rooms consist of a lounge with natural light, a small kitchenette, bathroom, toilet and two bedrooms. None of these areas have windows. The lounge furniture is shabby and torn in places and needs to be replaced. The previous owners had plans to proposal to improve the basement area by creating a bedroom from the existing lounge and to slightly expand in size the current bedroom occupied by one service user. By making these alterations the two bedrooms would be provided with natural light and ventilation, a feature currently missing from these areas. The new owners of the home have not yet addressed this. The laundry is outside in a small extension. All the equipment is domestic in style and in working order. Belgrave Terrace DS0000071699.V371492.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems around recruitment, selection and training of staff are good and meet the range of needs of the people using the service and protect them from harm. EVIDENCE: There are currently seven people living in the home. The registered manager only has ten hours supernumerary time to carry out all aspects of management of the home. During the day there are two staff on duty and overnight one member of staff “sleeps in”. One person has a one to one support for seventeen hours a week. Belgrave Terrace DS0000071699.V371492.R01.S.doc Version 5.2 Page 23 Two staff have recently left and the manager is actively trying to recruit new staff. Three staff files showed job application forms, two appropriate written references, proof of identity and Criminal Record Bureau checks as well as a record of the interview that had taken place. Staff have not yet received new contracts and job descriptions. Three staff have completed National Vocational Qualifications (NVQ) Level 3 and other staff are completing NVQ level 2. Other training includes, induction, health and safety, fire moving and assisting, food hygiene, disability awareness, dementia and safe handling of medicines. Belgrave Terrace DS0000071699.V371492.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run by a competent manager who makes sure that good quality assurance and safety systems are in place. This makes sure that people receive a good quality of care. EVIDENCE: The registered manger has several years experience in managing a care home. She has completed the Higher Diploma in the Management of services as well as the NVQ level 4 qualifications in management and care and the Registered Managers Award. In addition to these qualifications the manager has Belgrave Terrace DS0000071699.V371492.R01.S.doc Version 5.2 Page 25 completed a range of other training, such as the D32 and D33 Assessors Award, safe handling of medication, restraint and infection control. Regular audits are carried out in relation to some aspect of the service. These include health and safety checks,risk assessments, maintenance checks, as well as periodically sending out questionniares to people using the service and other professonals involved in their care. These reports are to make sure the quality of the home continually improves. The AQAA was completed and the information gave a brief picture of what was happening in the home. Further information would show about how it plans to develop over the next year. Regular meetings take place with staff and the people who live in the home so that everyone has the chance to discuss anything that concerns them. The records also record what is good about living in the home. Accidents are recorded and best practice guidance is used to track trends, which prevents as far as possible the same accidents occurring. Internal maintenance checks are up to date and external service certificates are available and up to date. Belgrave Terrace DS0000071699.V371492.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 3 4 3 5 2 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 2 25 2 26 2 27 2 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 3 2 X 3 X Belgrave Terrace DS0000071699.V371492.R01.S.doc Version 5.2 Page 27 New service. 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 4,5,6 Requirement The registered persons must provide a Statement of Purpose and ensure that the Service User Guide is written in plain English and made available in a language and format suitable for people to use and understand The registered persons must provide a new contract for the people living in the home, which sets out their terms and conditions. The registered persons must ensure that all medicines are stored according to the requirements from the Royal Pharmaceutical Society. The registered persons must ensure that the basement flat is refurbished and natural lighting provided. The registered persons must produce a planned maintenance and renewal programme for the fabric and decoration of the building. The registered persons must ensure that all radiators have suitable guards and low surface temperatures. DS0000071699.V371492.R01.S.doc Timescale for action 01/11/08 2 YA5 5 01/11/08 3 YA20 13 01/12/08 4 YA24 23 01/03/09 5 YA24 23 01/12/08 6 YA24 23 01/12/08 Belgrave Terrace Version 5.2 Page 28 7 YA27 23 8 YA30 13 9 10 YA33 YA40 18 10,12 The registered persons must ensure that suitable hand wash facilities are provided in all bathrooms and toilets The registered persons must ensure that staff have access to liquid soap and paper towels in all areas so that they can wash their hands effectively and reduce the risk of cross infection The registered persons must continue with the recruitment of care staff. The registered persons must ensure the home has up to date policies and procedures, which both staff and people living in the home have, access to. 01/12/08 01/11/08 31/01/09 01/12/08 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 YA17 YA33 Good Practice Recommendations It is highly recommended that the menus be written in large print and pictures styles. It is highly recommended that the manager is allocated more supernumerary hours. Belgrave Terrace DS0000071699.V371492.R01.S.doc Version 5.2 Page 29 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 Belgrave Terrace DS0000071699.V371492.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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