Care Home: Coanwood Drive

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What the care home does well The service involves service users in the assessment and planning process.The service has a good system for assessing people`s needs. This means that all parts of a person`s life are covered in the assessment and each person`s abilities, or strengths, as well as their needs are considered. Support and learning are planned with service users. By making goals achievable, and recognising what does and does not work, service users are less likely to fail. Staff support service users to learn new life skills. This helps them to become more independent. Service users are encouraged to use community transport and other local facilities. This helps service users to become part of the wider community. Visiting is encouraged so that service users are supported to keep in touch with their own friends and family. What has improved since the last inspection? Some parts of the home have been redecorated. Some specialised training for staff has been identified. This will help staff develop skills in supporting individual people who use the service. The way service users are involved in planning their care has been made more `user friendly`. CARE HOME ADULTS 18-65 Coanwood Drive 22 Coanwood Drive Mayfield Glade Cramlington Northumberland NE23 6TL Lead Inspector Carole McKay Key Unannounced Inspection 9th and 12th June 2008 11:50 Coanwood Drive DS0000000605.V365924.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 Coanwood Drive DS0000000605.V365924.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. Coanwood Drive DS0000000605.V365924.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coanwood Drive Address 22 Coanwood Drive Mayfield Glade Cramlington Northumberland NE23 6TL 01670 739319 F/P 01670 739319 coanwood@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 Mrs Marie S Johnson Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Coanwood Drive DS0000000605.V365924.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: 7 The maximum number of service users who can be accommodated is: 7 18th April 2007 Date of last inspection Brief Description of the Service: St Cuthbert’s Care is the charitable organisation providing the care at 22 Coanwood Drive. The property is owned and managed by the local authority housing department. The home is registered to provide care and support to seven adults with a learning disability. It is located in a residential area on the outskirts of Cramlington and is within walking distance of the town centre and public transport. Residents are accommodated at Coanwood Drive for a limited period of up to two years. During that time residents are helped by staff to develop the skills needed to live as independently as possible. A service is provided from Coanwood Drive to support people with learning disabilities who live in the community. Some of these people moved on from Coanwood Drive and levels of support vary to suit individual needs. Additional staff are to be provided for this service. The most up to date information that the Commission for Social Care Inspection has indicates that fees are £655.29 per week. Information about the service is available. The home has a copy of the Service User Guide and a copy of the last inspection report. Coanwood Drive DS0000000605.V365924.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 the people who use this service experience good quality outcomes. In line with current CSCI policy on ‘Proportionality’ the inspection focused upon a number of key standard outcomes for service users. How the inspection was carried out Before the visit: We looked at: • Information we have received since the last visit on 18th April 2007. • 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. • Surveys of the views of people who use the service and the staff. The Visit: Unannounced visits were made on 9th and 12th June 2008 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 parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit. Told the manager/provider what we found. What the service does well: The service involves service users in the assessment and planning process. Coanwood Drive DS0000000605.V365924.R01.S.doc Version 5.2 Page 6 The service has a good system for assessing people’s needs. This means that all parts of a person’s life are covered in the assessment and each person’s abilities, or strengths, as well as their needs are considered. Support and learning are planned with service users. By making goals achievable, and recognising what does and does not work, service users are less likely to fail. Staff support service users to learn new life skills. This helps them to become more independent. Service users are encouraged to use community transport and other local facilities. This helps service users to become part of the wider community. Visiting is encouraged so that service users are supported to keep in touch with their own friends and family. What has improved since the last inspection? What they could do better: Make sure that admissions into the home fit with the aims and objectives of the service so that all the people who come to live at the service in the future can be sure they will have their needs met. Make sure that they receive confirmation in writing that the people who commission the service (buy the service on behalf of the people who use it) are of the opinion that the service is properly resourced to meet the needs of the people who use the service. Coanwood Drive DS0000000605.V365924.R01.S.doc Version 5.2 Page 7 Find out from the staff team what it is they need to learn about so that they can support people who have needs other than those to do with having a learning disability. And provide this training so that confident staff care for people with more complex needs in the future. Give very clear and up to date guidance to staff about physical intervention, so that the people who may come to live at the service in the future, and current service users, are kept safe from harm. Make sure that complex medication arrangements are reviewed more frequently so that service users health needs are addressed. 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. Coanwood Drive DS0000000605.V365924.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Coanwood Drive DS0000000605.V365924.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 2 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 service will have their needs and wishes fully assessed. They will be involved in this throughout their stay at the home. EVIDENCE: In surveys for service users all but one of the people who returned a response said that they had been asked if they wanted to move into the service. One of the people who spoke to the inspector said that their admission to the home had been planned well and they had had several introductory visits. All but one person said that they had received enough information about the home prior to moving in. The care records were examined for a person who moved in to the home recently. These showed that several introductory visits had been arranged. And these had included brief visits for meals and introductions as well as overnight stays. Assessments of each person’s care needs are obtained by the home from the person’s care manager. The home carries out an initial assessment with each person over a period of time. The assessment process continues throughout Coanwood Drive DS0000000605.V365924.R01.S.doc Version 5.2 Page 10 the time a person lives at the home. This is because the service is designed to assess and support people to move out and live independently in the community. The assessments include things that service users have said about themselves and the things they want to achieve. The home has recently introduced a new additional assessment that involves the service user a lot more and that each service user will be able to help produce. This is called person centred care planning. A completed example was examined during the inspection. This was easy to read, because it included pictures and symbols. Despite this careful planning two recent admissions to the home had broken down. One person was about to move on to another kind of service and one person had been admitted back into hospital. One of these people said that they felt the home had not been the right kind of place for them and staff comments also supported this. The second person was not available to comment. But the care plan for this person was examined. It showed that this person had special needs to do with placing themselves at risk of harm. By reviewing the Statement of Purpose of the service and considering and consider whether these admissions, and any future admissions of this kind, are line with the aims and objectives it may be possible to avoid these breakdowns. If they are not in line with the aims and objectives, then admissions should be governed by new admission criteria. If they are in line with the aims and objectives, then the service needs to examine how it will support these kinds of admissions in the future. Coanwood Drive DS0000000605.V365924.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual care plans are comprehensive and regularly reviewed, so that all service users’ needs are recorded. EVIDENCE: Once a person’s needs have been assessed, an individual plan for each person is drawn up. Copies of these are in the service users’ records at the home. These cover all aspects of life and include a section on the personal preferences of the service user. To help staff follow the plan and understand the service users, a section identifying things that work and things that don’t work for the service user is included. Also peoples’ fears and concerns are written down along with how dreams can be turned into steps that are achievable. New ways of involving the people who use the service in designing their plans have recently been introduced. This helps the people to produce their own planning documents. These were examined during the visit to the service. Coanwood Drive DS0000000605.V365924.R01.S.doc Version 5.2 Page 12 Goals for making practical improvements towards independence are written down. After this each service user meets with the key worker who is helping them, to look at how well these plans are working. These are called Goal Evaluation Meetings (GEM) and they take place once per month. Notes from these meetings are kept in service users’ records. This helps service users to make their own decisions. Service users said that they could tell their key worker about any problems they have at these meetings. A misunderstanding arose from a review of the needs of a person who had recently left hospital. The agreements to do with risk of leaving the building was disputed by another professional and resulted in the person being re admitted to hospital. But generally risk taking has been well managed by the home in the past and continues to be so for less complex care. Service users are encouraged to take responsible risks as they go about their daily lives. Risks are carefully assessed and staff look at these from time to time and at the GEM meetings. Information that care managers give to the service and details of any risk assessments they have conducted, are sent to the home before an admission can take place. The home has a pre-admission assessment. This is used to establish how identified risks will be managed within and outside of the Home. Any risk assessment information is added into the service user plan. Completed risk assessment information was available in all of the care records examined. In surveys people who use the service confirmed that they are supported to make decisions. Coanwood Drive DS0000000605.V365924.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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 supported to become part of, and participate independently in, their local community. EVIDENCE: Each service user has a service user plan. These include goal plans to support people who use the service with managing specific areas of responsibility in their lives. Where people need a specialist care plan, the person’s care manager also carries this out. One of the people using the service has one of these. Service users are encouraged to make decisions about their plans. Each month they meet with their keyworker to discuss their goals. These meetings are recorded in full and were seen at this inspection. Service user plans at Coanwood Drive have a section dealing with education and occupation. Each service user has a weekly programme of activity that Coanwood Drive DS0000000605.V365924.R01.S.doc Version 5.2 Page 14 they are involved in devising. These are updated each week and show that each person has periods of engagement with work related and/or educational services. Routines are individual to each service user. During the inspection some service users were at home during the day and other people were out at services or work. Free time to relax and do nothing is also planned in. Visits to and from friends, including girlfriends and boyfriends, are planned out so that the people living at Coanwood sustain relationships that existed before they moved to the home. The home has rules. These have been put together through discussion with the people who live at the home and are written down. The service users said that they knew what the rules are. All the service users who were asked about these said that they thought they were reasonable. But one service user said that they felt that all persons do not comply with these rules and that the staff are not consistent in ensuring compliance. In surveys a staff member commented that being consistent was one of the things that could be done better. Menus are planned out for evening and weekend meals. Each day one or two people have full one to one support to shop and make a meal. Dietary needs are taken into account and all meals taken are recorded. Healthy eating is promoted in the home, though the staff do not govern choices that people make. Coanwood Drive DS0000000605.V365924.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. 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. Personal support is provided to service users in line with their abilities and preferences. EVIDENCE: The people who live at the service are very independent and need no support with personal care, but some people may need prompting. There was evidence in the files that the people using the service are supported, as necessary, to obtain advice on health and personal matters through the use of local GP practices and other support services. Two people have care needs to do with maintaining good mental health. The care records show that specialist help is used when necessary. These arrangements have been reviewed but the care plan does not describe the special review arrangements. Service users attend appointments independently where they can and support is provided for some people. Coanwood Drive DS0000000605.V365924.R01.S.doc Version 5.2 Page 16 A medication policy is in place for staff to refer to. The manager, Marie, said that one of the staff has been delegated to take the lead for looking after medications and regularly audits the records. The responsibilities that this person carries are not written down anywhere. This person has had the same medication training as the rest of the staff, but nothing beyond this. Some of the people living at Coanwood look after their own medication. Where this happens there is evidence that the home has arrangements to monitor and review this. A small amount of medication is held for safekeeping by the staff for some service users. The risk assessment process identifies who needs help with this and care plans are in place to describe the arrangements. The medication storage is adequate. The home has no controlled medication in stock but has obtained a register for these. The records were up to date and fully completed. One of the people who live at the home has a complex medication regime. This came with the person when they left hospital. The regime makes for difficulties in timing of medications because of the way the medicines interact. This was discussed with the manager and it was suggested that a review of this person’s medication should be discussed with the specialist concerned in the persons’ care. Coanwood Drive DS0000000605.V365924.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. 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. The people who live at the service are protected from harm and know how to raise their concerns. EVIDENCE: The home has a policy and procedure for protecting its service users. This complies with guidance issued. An adult protection issue has been handled properly, since the last inspection. CSCI was informed about this. Since the last inspection the staff have attended updated training in safeguarding vulnerable people from abuse. Their employer delivered some of this training and some by the Local Authority team who handle safeguarding vulnerable adults. But staff are not clear and consistent in their understanding around the use of physical intervention in the care setting. In surveys, the people who use the service all confirmed that they knew how to make a complaint and whom they should speak to if they were unhappy. And staff were positive about handling concerns. People said that they would raise their concerns. The person who looks after the home for the provider visits once per month and since the last inspection they have met with the service users. Coanwood Drive DS0000000605.V365924.R01.S.doc Version 5.2 Page 18 A simple to read version of the complaints procedure has been included in the new person centred care plan document (PCP). CSCI has not received any concerns about the service since the last inspection. Coanwood Drive DS0000000605.V365924.R01.S.doc Version 5.2 Page 19 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 adequate. This judgement has been made using available evidence including a visit to this service. The home is clean and comfortable. However the front flower beds are neglected and this lets down the appearance of the home. EVIDENCE: Coanwood Drive is comfortably furnished and the home is clean throughout. Local bus routes pass by near the home and service users said that they use public transport regularly. The premises are in keeping with the local housing and no signage denotes that it is a registered home. There is a system for auditing the fabric and fittings of the building. The home has one living room, one dining room, an office, a utility room and a bathroom and a kitchen on the ground floor. The bedrooms are all on the first floor. These rooms are quite small. The living room, dining room and office are accessed from the front door through the kitchen. There is no alternative communal area. Visitors are accommodated in the office or in the dining or Coanwood Drive DS0000000605.V365924.R01.S.doc Version 5.2 Page 20 living room. The manager, Marie, said that she is hoping that a conservatory will be built on to the rear of the home, so that a second communal area is available for receiving visitors. The grounds are not so well maintained, but the home does not have a gardener. The people who use the service are encouraged to look after the gardens with the staff. But the interests and abilities of the people who are living at the home at any given time determine this. In surveys the people who live in the home responded that it is always (4) or sometimes (1) fresh and clean. The people who live at the service are encouraged to take some responsibility for this and the home employs a part time cleaner. Washing machines are located in the utility room. This is accessed directly from the main entrance corridor, so that people who use the service do not need to take laundry through food preparation areas. The overflow pipe from the water tank is leaking and the manager has reported this. The plumbers arrived at the end of the inspection and found that the water tank in the attic would need to be replaced. Temporary arrangements were being considered for the accommodation of the people living at the service, if necessary. The staff training record shows that staff receive training in the control of infection. Risk assessments for safety have been carried out. Coanwood Drive DS0000000605.V365924.R01.S.doc Version 5.2 Page 21 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): 32,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are properly recruited and receive good basic training, so that people are protected and supported. EVIDENCE: A total of eleven staff in total are employed at the home. Two of these are non-care staff. The home has a full staff complement and there has been no staff turnover in the past 12 months. The staff team supports a small group of people living in the community and Marie said that this is placing increasing demands on the staff group. But there is a plan to create a separate team of staff for this in the future. In surveys two of the staff who responded answered that that there is always enough staff. Two staff responded usually and one person responded sometimes. The recruitment of staff is managed from the head office of St Cuthbert’s Care There is evidence in the home of how this is organised and that proper checks are carried out. The manager said that the full records are held at the head Coanwood Drive DS0000000605.V365924.R01.S.doc Version 5.2 Page 22 office of the organisation. These were not examined at this inspection. Marie said that staff and service users are involved in the interviews for new staff. Of the five staff who responded to the survey one said that the induction covered the things they needed to know very well, and four responded mostly. All confirmed that pre employment checks had been carried out. Two staff who responded said that they always have the support/ experience/ knowledge to deliver the care that service users need. Two staff responded usually to the same question. Staff said that they felt supported by the organisation and that they received enough training. But have noticed a significant change in the needs of service user who are being referred to the service by care managers and acknowledged that this would raise new training needs in the future. The staff training matrix was examined. Two staff received awareness training in the Mental Capacity Act in 2007. One member of staff received training in working with mental health needs in 2003. All staff have received training in non-violent crisis intervention; one in 2005, one in 2006, six in 2007 and two in 2008. None of the staff have received training in the Mental Health Act. A training needs and impact assessment for the whole team has not been carried out. But the training records show that some specialist training has been delivered in the past year. For example staff have received training in head injury and in responding to challenging behaviour. Four of the staff hold a national vocational qualification (NVQ) in care and five are working toward this. Coanwood Drive DS0000000605.V365924.R01.S.doc Version 5.2 Page 23 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 people living at the service influence the way the service is managed. The people who live there are kept safe and encouraged to take responsibility for this as far as their abilities allow. EVIDENCE: The registered manager has the required qualification and experience. There is a safety and maintenance audit process. Members of the staff team hold responsibilities to do with this. The staff are not involved in moving and handling of people but they receive training in moving and handling of loads. First Aid and Health and Safety training is provided to staff. Coanwood Drive DS0000000605.V365924.R01.S.doc Version 5.2 Page 24 The records show that safety risk assessments are carried out for fire, hazardous substances, and infection. Guidance about these things is written down and available for staff. Induction and regular up dated training is provided to staff in health and safety, first aid, food safety and fire safety. The fire alarm and fire equipment tests and servicing is recorded and up to date. Portable electrical appliances are tested annually. These were last tested in October 2007. All the staff have received training in infection control and recent guidance is in place. Risk assessments for the control of hazardous substances are in place. Secure storage is available on the ground floor. Regular meetings take place between individual service users and their key workers. Also, group meetings take place every month. These meetings are recorded. Action plans are developed from these. Service users said that they are encouraged to voice their opinions. A representative from the organisation that provides the service, St Cuthbert’s Care, visits the home once per month. Reports are produced from these visits. The manager said that a new reporting form was about to be introduced. And that this would reflect the emphasis on the person centred approach to care. Coanwood Drive DS0000000605.V365924.R01.S.doc Version 5.2 Page 25 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 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 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 3 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 4 14 X 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Coanwood Drive DS0000000605.V365924.R01.S.doc Version 5.2 Page 26 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 6 Requirement The registered persons must carry out a review of the service Statement of Purpose and Aims and Objectives, and admission criteria, to ensure that admissions to the service of people who remain under a provision of The Mental Health Act 1983 are appropriate to the staffing and resources the home can offer. A copy of the review outcome must be sent to the inspector. The registered manager must confirm with the inspector the arrangements for repair of the heating system. The registered manager must carry out a written training needs assessment for the team as a whole that takes account of referrals to the home for people who have mental health needs and who may remain under a section of the Mental Health Act. Timescale for action 18/08/08 3 YA24 23 31/07/08 4 YA35 18(1)(c) 31/10/08 Coanwood Drive DS0000000605.V365924.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 Refer to Standard YA24 Good Practice Recommendations Serious consideration should be given to improving the front aspect of the home with low maintenance land scaping. Serious consideration should be given to providing an alternative communal space and/or meeting room. 2 3 YA20 A review of medication should be arranged for one of the service users whose medication regime is complex. The responsibilities of the staff member who leads on medication should be written down and consideration should be given to this person receiving additional medication training to that of other staff. One example of this is training delivered specifically for providers of services for people with learning disabilities from organisations such as ARC, as referred to in the CSCI guidance ‘ Training care workers to safely administer medicines in care homes.’ The registered manager and staff must be provided with a copy of the DOH document Guidance on Restrictive Physical Interventions for People with Learning Disability and Autistic Spectrum Disorder, in Health, Education and Social Care Settings. The registered manager should send copies of the Regulation 26 visit reports for August and September 2008 to the inspector. YA20 4 YA23 5 YA39 Coanwood Drive DS0000000605.V365924.R01.S.doc Version 5.2 Page 28 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 Coanwood Drive DS0000000605.V365924.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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