Care Home: Ivy Dene

Similar services:

• Larch Avenue
• Alderson Road 12
• Cranworth Close Registered Care Home
• The Cornerstone
• John Street Nursing Home
• Pennine Camphill
• Whitwood House
• Whitwood Hall

What the care home does well The home was well decorated and provided a homely atmosphere for people to sit and join in activities. The home was also very clean and tidy and the staff work hard to maintain the high standards. The atmosphere was very relaxed and the people that use the service were seen to be very happy and comfortable in their surroundings. Visitors and staff spoken to by the inspector said the manager was always `friendly` and `helpful`. Discussions with relatives and outside professionals suggested that the staff know to look after the people in the home properly and keep them safe. Most of the time the same carers work with each person that lives at the home. This means that they get used to each other and the individuals involved feel comfortable with the care that they receive. Visitors to the home said that they were made to feel welcome by staff and that they can visit whenever they please. One person said its an `excellent home`.People that use the service have good access to the community and the care staff have supported them to go to activities in the community that they enjoy. What has improved since the last inspection? There were no areas of concern that needed to be improved at the last inspection. What the care home could do better: Some of the records in the home could be recorded in a more consistent way, this would help to make sure that everyone understands what is meant by what is recorded and the records would give a better picture of how life is for the people that use the services provided by the home. Peoples care plans and risk assessments should be looked at on a more regular basis to make sure that they are still right for the people that they concern. This will help to make sure that people that use the service have their needs met in a way that is acceptable to them. The environment in the home is generally good, however the carpets in the downstairs lounge and dining areas could cause trip and fall hazards to people passing through these areas and should be either repaired or be replaced to support the health and safety of the people that use the service. CARE HOME ADULTS 18-65 Ivy Dene 20-22 Doncaster Road Ferrybridge Knottingley WF11 8NT Lead Inspector Stephen Robertshaw Key Unannounced Inspection 12th August 2008 9:00 Ivy Dene DS0000037871.V371261.R02.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 Ivy Dene DS0000037871.V371261.R02.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. Ivy Dene DS0000037871.V371261.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ivy Dene Address 20-22 Doncaster Road Ferrybridge Knottingley WF11 8NT 01977 671499 01977 672370 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) Ivy Cottage (Ackton) Limited Care Home 14 Category(ies) of Learning disability (13), Physical disability (1) registration, with number of places Ivy Dene DS0000037871.V371261.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th September 2006 Brief Description of the Service: Ivy Dene is a care home providing personal care and accommodation for 13 adults with a learning disability and who may exhibit challenging behaviours and 1 person with a physical disability. The home is owned by Ivy Cottage (Ackton) Ltd, a small private company with two other residential homes catering for similar service user groups. The home is situated close to the centre of Ferrybridge where there are shops including a post office, pharmacy, fish and chip shop, public houses and a community centre. There is car parking to the front of the property and there is a main bus route nearby. The home is quite close to the A1, M1 and M62 link roads and the centre of Pontefract is only a few minutes’ journey from the home. The service, which has been operating for about five and a half years, it is situated in a former older persons’ home and provides accommodation on 2 levels. An upper floor flat, which has a separate entrance, is used as a semiindependent unit for 4 of the more able people accommodated. The service provides single accommodation throughout and has appropriate communal facilities, which meet the needs of people presently accommodated. Weekly fees within the home at the time of the inspection ranged from £2,000 to £2,600 dependent on the assessed needs of individuals. 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. Ivy Dene DS0000037871.V371261.R02.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. The Commission made a site visit to the service on 12 August 2008 The inspection was unannounced and we where in the home for approximately six and a half hours. The information that has influenced this report includes speaking with people that used the service, interviews with management, staff and visitors to the home. It also included observing documentation held by the service and taking I to account any information that the Commission had received since the last inspection of the service. The Commission would like to thank everyone for making them welcome at the home. We have not received any information about this service that gives cause for concern and would make us think that the current quality rating is not accurate. What the service does well: The home was well decorated and provided a homely atmosphere for people to sit and join in activities. The home was also very clean and tidy and the staff work hard to maintain the high standards. The atmosphere was very relaxed and the people that use the service were seen to be very happy and comfortable in their surroundings. Visitors and staff spoken to by the inspector said the manager was always ‘friendly’ and ‘helpful’. Discussions with relatives and outside professionals suggested that the staff know to look after the people in the home properly and keep them safe. Most of the time the same carers work with each person that lives at the home. This means that they get used to each other and the individuals involved feel comfortable with the care that they receive. Visitors to the home said that they were made to feel welcome by staff and that they can visit whenever they please. One person said its an ‘excellent home’. Ivy Dene DS0000037871.V371261.R02.S.doc Version 5.2 Page 6 People that use the service have good access to the community and the care staff have supported them to go to activities in the community that they enjoy. 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. Ivy Dene DS0000037871.V371261.R02.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 Ivy Dene DS0000037871.V371261.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 ,3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that people who are wanting to move to the home have their needs fully assessed before they are admitted to make sure that the home will be able to safely care for them. EVIDENCE: We looked at the care file information for three of the people that use the service. All of these included a full assessment of the care needs of the individuals that were admitted to the home. The assessments of need were comprehensive and were a combination of the placing authority’s recorded information and the homes pre-admission assessment. This helped to identify that all of the individuals needs could be supported through the services provided by the home. The homes statement of purpose and service user guide also detailed the services that are available through the home and what would be made available through the fees that were being charged. It also gave details of the management structure of the service. Ivy Dene DS0000037871.V371261.R02.S.doc Version 5.2 Page 9 Direct observations on the day of the site visit, observation of peoples care files and staff personnel and training files supported the evidence that the home has the capacity to meet the assessed needs of the people that use the service. The care files also supported that people had the opportunity to visit the home before a decision was made to move there on a more permanent basis. When people are admitted to the home they are provided with a welcome basket, this includes toiletries, a robe and pyjamas. This is to make sure that they have all of the basic things to maintain their personal hygiene. One person told the Commission ‘I’ve been here a long time now and I’ve still got things in my basket’. Ivy Dene DS0000037871.V371261.R02.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that people that use the service have full care plans that state the support that they need to live their lives to their full potential. EVIDENCE: The Commission looked at the care plans for three of the people that use the service. The quality of the care plans was variable, however some of the care plans were of a very good standard detailing the actual need and the support that the individual would need to meet these needs The care plans would benefit from being reviewed on a more regular basis to make sure that they are still relevant to the individuals needs. Ivy Dene DS0000037871.V371261.R02.S.doc Version 5.2 Page 11 The care staff and management should be aware that when new care needs are identified old ones should not be crossed off, new care plans should be introduced to avoid any confusion. The people that are involved in developing the care plans or completing any other documentation in the home should sign the documents so that at a later stage if that information is required the person who made the records can be identified. The care plans were also supported with risk assessments where appropriate. Again these should be evaluated on a more regular basis to make sure that they are still relevant. Direct observations of staff interacting with people that use the service clearly supported the evidence that they understood the care plans and the needs of the people that they were supporting. There was also evidence to support that individuals are encouraged and supported in writing their own care plans. On the day of the site visit one of the people that uses the services had a review of their care at the home and included their social worker. He told us about the meeting and what he had agreed to do. Daily diary records show the activities that the individuals had been involved in on a daily basis. Some of these records were very thorough and the senior management of the service were made aware of how good some of these records were. People that use the service are encouraged to make decisions for themselves throughout their daily lives and staff and individuals were observed discussing what they wanted to do and the support that they needed to carry out any tasks. This included one person that had problems with their mobile phone and the staff helped them to find their personal number so that they could be contacted when they went out from the home. He said ‘the staff are good, I go out on my own and they ask where I go’. Regular meetings take place between the staff and the people that use the service to identify how they see their care being delivered and to look at how services can be improved to help the people that are living at the home. The people that use the service have their own personal bank accounts and, dependent on personal preference, the bankbook and monies are either kept in their individual rooms or are locked in the office. Access to the bank books held in the homes safe is gained through requests made to a staff member and is available at all times of the day. Care plans were identified in individuals care files showing the support that they required to deal with their budgeting and general finances. Ivy Dene DS0000037871.V371261.R02.S.doc Version 5.2 Page 12 The staff that were spoken to by the Commission had a clear understanding of the individual needs and care plans and the personal limitations of the people that they were responsible for in their care. Ivy Dene DS0000037871.V371261.R02.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 good. This judgement has been made using available evidence including a visit to this service. This means that people that use the service are supported and encouraged to maintain and develop their personal lifestyles and interests while they are living at the home. EVIDENCE: The documentation in the home, direct observations and interviews with staff and people that use the service supported the evidence that individuals are supported and encouraged to take part in activities in the home and in the community that are stimulating and of personal interest to the people that are involved in them. The activity co-ordination was not available on the day of the inspection, however the care staff supported that a full programme of group and individual activities are available on a daily basis at the home. One persons care file showed that they recently went to watch Manchester United Ivy Dene DS0000037871.V371261.R02.S.doc Version 5.2 Page 14 in a European match and another person told us how they enjoy to go to watch the local Rugby team play their home matches. He said that he enjoyed going to the games and commented that ‘the staff here are trying to get me a voluntary job down at the ground’ he also said that this would be ‘great if I get a job, because I would see all of the players’. This was later confirmed in discussions with the staff team. Documents that were observed, interviews with staff, and observation of photographs supported the evidence that people that use the service had been given the opportunity to go on holiday to the Norfolk broads. Staff rotas that were seen following the site visit to the home supported that sufficient staff are always on duty to make sure that people are able to access activities that are of interest to them with support from the staff if they require any. Records showed that activities including swimming, cinema trips, gardening, visits to local nightclubs, shopping, arts and crafts and computers are regularly made available to people that use the service. One of the people that use the service uses to computer to calm him down when he is feeling anxious. People are encouraged to maintain and develop relationships with their families and friends that are living in the community. One person said ‘I’m going to see my mum this afternoon, I go to see her a lot’. Mealtimes at the home were observed to be very relaxed and friendly. People appeared to be enjoying their breakfasts and lunches. Individuals had made a choice about what they wanted to eat and appeared to be happy with their meals. The people that use the service have choices at all of their meal times at the home, however they are encouraged to follow a healthy, nutritional and balanced diet. The home have been awarded 5 stars out of 5 from the local authority in relation to the food hygiene and preparation of food at the home. Ivy Dene DS0000037871.V371261.R02.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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that people can be confident that their personal and healthcare needs while they are living at the home. EVIDENCE: The documentation in the home observed by the Commission supported the evidence people are provided with the choice of General Practitioner and are supported to access more specialist assistance when required. This included services through psychology, psychiatry and district nursing services. The service closely monitors the individual’s health care needs and if any problems are identified they are referred on to the appropriate health care professional. Regular appointments with dentists and opticians are maintained and any contact with professional health care workers are recorded in individual s care files. Medication is reviewed frequently. The prescribed medication in the home uses a Nomad blister system to assist in the administration of the medication. All staff that administer prescribed Ivy Dene DS0000037871.V371261.R02.S.doc Version 5.2 Page 16 medication in the home have received accredited medication training. All of the medication records that were observed were up to date and had been accurately recorded. Records of medication entering the home and being returned to the pharmacy were also up to date and had been accurately recorded. People that use the service are assessed to see if they have the ability to self medicate and if they are them a risk assessment is completed with close monitoring of the administration from staff. Good practice in relation to the prescribed medication used in the home is that the actual medication guidelines are easy to follow and possible side effects are brought to the attention of the staff group. Individual medication record sheets had been colour coded to identify the same type of medications. At the time of the site visit there was nobody in the home that had been prescribed controlled medication. However the service had appropriate safe storage facilities available for controlled drugs. The home did not have a controlled drugs register available. The home has a policy and procedure for emergency admissions to the home and this states that nobody may be admitted to the home that has been prescribed controlled medication. Individuals care files also included their optical prescriptions where appropriate and these had all been reviewed on regular intervals. Peoples care plans also identified if they had any allergies that may affect their daily lives Ivy Dene DS0000037871.V371261.R02.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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that people that use the service have their rights protected, and there are clear complaints and safeguarding policies and procedures in the home to support the care for the people that use the service. EVIDENCE: We looked at the homes complaints and safeguarding adults registers. There had been no formal complaints received directly by the home or the Commission since the last inspection. Also there had been no referrals made to the local safeguarding adults team. The complaints procedure is left in an open area of the home and the care staff stated that if people did not understand the written policy then they would try to explain it to them in ands easier way. Interviews with care staff supported the evidence that they understood what safeguarding issues were and that they knew how to appropriately refer any suspicions or allegations to the correct bodies. Staff training records also showed that they undertake safeguarding adults training. Some of this training is provided through National Vocational Qualifications (NVQ), local authority training and outside training agencies. Ivy Dene DS0000037871.V371261.R02.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): 24, 25, 27, 28 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the home provides a comfortable and homely environment for the people that use the service, however there are some small areas of the environment that could be improved. EVIDENCE: As part of the site visit to the service the Commission made a tour of the premises and the grounds to help to access the quality of the environment. The home was free from any offensive odours and was suitable for its intended purpose. Ivy Dene was safe and was accessible for all of the people that currently use the services of the home. Ivy Dene DS0000037871.V371261.R02.S.doc Version 5.2 Page 19 The communal rooms were generally well decorated and furnished providing a homely and comfortable environment. On the day of the inspection, the home was clean and tidy and no offensive odours were present. Three of the people that use the home invited the Commission to look around their personal rooms. These had all be decorated and furnished in line with their personal tastes and preferences. One of the people was very proud of his room and said ‘I like to keep it tidy’ he also said that it helped him to ‘get ready’ for living in the community on his own at a later stage. One of the people that use the services of the home has hearing problems and so their mattress and pillow vibrate to let them know if somebody wants to enter their room or makes them aware of any fire alarms. The carpets in the downstairs lounge and dining area looked as if they needed to be either repaired or replaced to minimise any risks of trips or falls to people accessing these areas. The dining area would also benefit from some redecoration to create a more homely and comfortable environment. The majority of the homes maintenance and servicing records were available and were up to date. The person in charge on the day of the site visit was not able to demonstrate that the home had a current electrical hard wiring safety certificate, however they stated that this was possibly in the managers personal drawer and when located a copy would be forwarded to the Commission. Staff training records supported that all staff receives infection control training when they begin to work at the home. The home were observed to have good stocks of infection control equipment. Ivy Dene DS0000037871.V371261.R02.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): 32, 33, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the staff working at the home have the necessary skills and knowledge to safely care for the people that use the service. EVIDENCE: We spoke with five of the staff that work at the home and they were all very clear of their own responsibilities and those of their colleagues. We also looked at the staff personnel and training files for four of the staff that work at the home. The staff training records that were observed supported the evidence that all of the home staff receive all of the mandatory training and refresher training that is expected of them. Staff interviews also supported that staff are provided with specialist disability awareness, equality and diversity and service users specific training including autism and challenging behaviour training. The home uses a computer system, which helps to identify when refresher training is due in order so that this can be arranged and helps to make sure Ivy Dene DS0000037871.V371261.R02.S.doc Version 5.2 Page 21 ensure that the level of care that people receive at the home not compromised in any way. The home has access to both external and internal training providers. The management of the service said that the home has access to an adequate training budget to ensure all staff have fair access to the full range of training being provided. One member of staff stated ‘we are always training, sometimes it seems like we train more that we are at work, but at least we know what to do and understand peoples individual need more clearly’. Direct observations supported that evidence that staff have good working relationships with the people that use the service and support them to have as independent lifestyles as possible within risk-assessed parameters. The staff personnel files that were observed by the Commission included all of the relevant information that is required by regulation. This included Criminal Record Bureau (CRB) safety checks and a minimum of two references, one work related and one personal. This helps to protect the people that live at the home from possible abusive situations. Clear records of the interview process and included on individual staff files. Interviews with management and care staff showed that people that use the service are involved in the interview process for prospective new staff to the home. The home and care staff are very committed towards National Vocational Qualifications (NVQ) training in care and approximately 80 of the homes staff have completed NVQ 2 in care. Approximately 4 of the care staff have completed NVQ 3 in care. Staff supervision records were not observed b y the Commission, however care staff stated that they receive regular formal supervision. When staff are on duty at the home their photographs are displayed so that the people that use the service know who is working and who they can look for if they need any support. Ivy Dene DS0000037871.V371261.R02.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): 37, 38 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the management of the home have a clear understanding of the needs of the people that use the service and the needs of the staff group. EVIDENCE: The registered manager of the service has recently left the service. The management need to return their registration certificate to the Commission to be amended. On the day of the site visit the service was being overseen by an acting deputy manager who had the support of the senior management team including the services area and general managers who are based in the home itself. The Commission were informed that the service is actively recruiting for a new Ivy Dene DS0000037871.V371261.R02.S.doc Version 5.2 Page 23 manager and once they are appointed they will be making an application to the Commission to be recognised as the homes registered manager once their induction period has been completed. The service operates regular quality assurance checks within the home to ensure people receive a good quality service. Meetings are held on a regular basis with the people that use the service and the staff group. This helps to support the quality assurance program within the home. This could be improved with the inclusion of outside professionals being consulted to ask their opinions in relation to the services being provided by the home. The service has also received an Investors In People Qualification and this also supports the quality of care being provided through Ivy Dene. The management of the service makes sure that, so far as is reasonably practicable, the health, safety and welfare of residents and staff is protected. Except for the previously identified electrical systems safety certificate all other equipment maintenance and service records were up to date including fire checks and drills. Ivy Dene DS0000037871.V371261.R02.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 3 2 3 3 3 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 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 3 12 4 13 4 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X 3 3 X Ivy Dene DS0000037871.V371261.R02.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. Refer to Standard YA6 Good Practice Recommendations The registered person should make sure that individual care plans are evaluated on a more regular basis to make sure that they are still appropriate to the individuals concerned and make sure that their needs are being met. The registered person should make sure that when risk assessments are completed to support care plans they are regularly reviewed to make sure that they are still appropriate. The registered person should replace or repair the carpets in the downstairs lounge and dining room to create a more homely and safe environment for the people that access these areas. The management of the service should continue in their attempts to employ a person that will become the registered manager of the home. This will help to maintain the service and make sure that the environment and the services that are provided are safe and appropriate. 2. YA9 3. YA24 4. YA37 Ivy Dene DS0000037871.V371261.R02.S.doc Version 5.2 Page 26 5. YA41 The registered person should make sure that all documents in the home are recorded consistently and the people that complete the records include their names and dates on them to identify when they had been completed and by whom. Ivy Dene DS0000037871.V371261.R02.S.doc Version 5.2 Page 27 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 Ivy Dene DS0000037871.V371261.R02.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!