Care Home: Midmoor Road (19)

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What the care home does well The home continues to encourage and offer good support to enable service users to access local community services and facilities. Service users access a wide range of community facilities and staff also supports service users with taking part in a wide range of activities inside the home. Staff receive good training opportunities. The assistant team leader who is currently managing the service runs the home for the benefit of service users. She has a good understanding of their needs and promotes individual choice as much as possible. What has improved since the last inspection? One bathroom has been fitted with new flooring to ensure that the surface is watertight, easy to maintain and prevents the risk of any infections. The dining room and hallway have been decorated and new furniture has been provided in the dining room. Some of the bedrooms have been decorated and the sensory room has been refurbished. Some of the homes standard documents have improved and more information is now included in the terms and conditions of residence/contracts. Service users have been able to access a greater range of holidays and also express their choice and interests in developing new activities. What the care home could do better: The home must not admit people to the service without ensuring that a full assessment is completed. Individual written care plans must be kept up to date in order to demonstrate how staff assist service users with their assessed needs. Documentation that is used by the "Trust" should be updated to include information about them as owners. As stated above part of these documents include the complaints procedure leaflet that needs updating. When staff are issuing prescribed medicines a written record must always be maintained if for any reason medicines are omitted. Doors on cupboards that are identified, as Fire doors must be kept locked and fire doors must not be wedged open. CARE HOME ADULTS 18-65 Midmoor Road (19) Pallion Sunderland SR4 6UP Lead Inspector Clifford Renwick Key Unannounced Inspection 30th October 2008 10:00 Midmoor Road (19) DS0000015773.V372941.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 Midmoor Road (19) DS0000015773.V372941.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. Midmoor Road (19) DS0000015773.V372941.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Midmoor Road (19) Address Pallion Sunderland SR4 6UP 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) 0191 510 3612 0191 510 8099 ntawnt.midmoor@nhs.net Northumberland, Tyne & Wear NHS Trust manager post vacant Care Home 6 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (1), Physical disability (5), of places Physical disability over 65 years of age (1) Midmoor Road (19) DS0000015773.V372941.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st October 2006 Brief Description of the Service: Midmoor Road is a small registered care home, run by Northumberland and Tyne and Wear NHS Trust. It provides personal care and support services for up to six people who have a learning disability and may also have difficulties with mobility. The home is not registered to provide an emergency admission service, and it cannot provide nursing care. Accommodation is provided in a spacious purpose built detached bungalow, which stands in its own enclosed gardens with extra space for off street parking. It is situated in a residential area of Sunderland and is within easy reach of local shops, parks, Churches, pubs and other facilities. The area is well served by public transport and people living at the home have the use of a privately owned ‘people carrier’ too. Closed circuit television (CCTV) is not used within the home, but it is installed outside at the entrance and in the parking area to ensure the security of the people living and working there. The weekly fee is £997.41 and each service user makes a contribution towards this. In addition to this the Trust issues an annual clothing allowance of £320.00 and an annual holiday allowance £320.00 to each service user. Midmoor Road (19) DS0000015773.V372941.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. 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 quality rating for this service is 2 stars. 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 last visits in October 2006 and from the annual service review that was completed in 2007. How the service dealt with any complaints & concerns since the last visit. Any changes to how the service is run. The provider’s view of how well they care for people. The provider in the annual quality assurance assessment (AQAA) submitted information to confirm what they are doing in the service. The Visit: An unannounced visit was made on the 30th October 2008. During the visit we: • • • • • • Observed care practices being carried out with 4 of the people who live in the home by staff that was on duty. Held discussion with the assistant team leader who is currently managing the service. Looked at information about the people who live in the home & how well their needs are met. Looked at other records which must be kept in relation to health and safety and staffing. Checked that staff had the knowledge, skills & training to meet the needs of the people they care for. Looked around the home to make sure it was well maintained, safe and free of any hazards. DS0000015773.V372941.R01.S.doc Version 5.2 Page 6 Midmoor Road (19) • • We also gathered information from looking at care records to assess how staff supports the residents with their assessed needs. We also focused upon looking at care files for 2 residents as a part of the inspection we refer to this as “case tracking”. And this involves looking at all records of the care for a named individual. We told the staff what we had found. None of the service users use speech as a way of communicating and one person uses some hand gestures as a way of expressing himself or herself. Consequently discussion was not held with service users but time was spent observing how staff interacted with service users using speech, hand gestures and observation of body language in order to form judgements about how well they care for people. What the service does well: What has improved since the last inspection? One bathroom has been fitted with new flooring to ensure that the surface is watertight, easy to maintain and prevents the risk of any infections. The dining room and hallway have been decorated and new furniture has been provided in the dining room. Some of the bedrooms have been decorated and the sensory room has been refurbished. Some of the homes standard documents have improved and more information is now included in the terms and conditions of residence/contracts. Service users have been able to access a greater range of holidays and also express their choice and interests in developing new activities. Midmoor Road (19) DS0000015773.V372941.R01.S.doc Version 5.2 Page 7 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. Midmoor Road (19) DS0000015773.V372941.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 Midmoor Road (19) DS0000015773.V372941.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): 2&5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. For any individual wanting to move into the home a full written assessment is not always carried to ensure that their needs can be met. Each service user has an individual contract in their files informing of the homes terms and conditions. Some of these need updating as not all of the information in the agreement is accurate. EVIDENCE: One new person has moved into the home since the last visit and information held in this persons file confirmed that they had had the opportunity to visit the service prior to moving in. These pre visits assisted staff with the assessment process however there was little information recorded as to what needs were identified during these visits. The pre assessment document had not been fully completed prior to admission. There were a number of areas that related to personal care where information had not been recorded but had been sought verbally by staff. Midmoor Road (19) DS0000015773.V372941.R01.S.doc Version 5.2 Page 10 And little information had been provided by the “Trusts” other home where the person had been living for 12 years. Consequently it was not clear as to how this assessment document led to an individual care plan being developed. In discussion with staff it was evident that they had compiled a good knowledge base of this persons needs though as stated this is not recorded in the assessment document. And it was clear from entries made in the daily records that staff was meeting this persons needs. The care plan that is in place for this person is discussed more fully in sections 6 – 10 of this report. The terms and conditions of residence, which are referred to as the service user agreement, are in written and pictorial format. They are easy to read but some amendment is required as the back page still contains information about the previous owners whereas the front page lists the current owners. The agreement also makes reference to Paragraph 10 for any service user wishing to contact the commission. Though there is no paragraph 10 with paragraph 9 being the last paragraph. These appear to be typographical errors and were discussed with the person in charge at the time of the visit. Midmoor Road (19) DS0000015773.V372941.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 adequate. This judgement has been made using available evidence including a visit to this service. An individual plan for each service user sets out how assessed needs are met and how service users are supported to make choices and take risks as part of living an independent lifestyle. However there is insufficient detail to show how staff meets changing needs. EVIDENCE: As part of case tracking exercise two service users file were looked at. Comprehensive Care Management assessments were available for one person as well as the home’s own assessment. Each plan of care is regularly evaluated and any changes are recorded appropriately. Midmoor Road (19) DS0000015773.V372941.R01.S.doc Version 5.2 Page 12 Though the pre admission assessment for the person who has recently moved into the home was not detailed. Staff have now carried out a more thorough assessment particularly in relation to eating and drinking. This has resulted in advice and support being received form a language therapist. And in turn this has lead to a clear and detailed care plan being implemented. The care plans for both persons are in both written and pictorial format and easy to understand and demonstrate how a consistent approach is taken by staff when working with the person. The individual care plans are written in such a way that it reflects the choices of each individual and also involves the service user wherever it is practically possible. Staff are currently working on transferring written information from service users care files onto the “trusts” new documentation. As such some information has not yet been fully transferred onto the new format. One file was neatly set out with index separators and a contents sheet making the retrieval of information easy. Whereas the other file was not and it was difficult to find information about the care needs. There are also some areas of information that are not included in the care plan but should be as staff are carrying out specific actions with a particular aspect of care. This was discussed with the staff on duty and who were able to offer a good explanation of what they were trying to achieve and how consistent support was offered to the person. It was positive to note that staff are carrying out regular assessments of risks and especially whether any specialised equipment is in use to assist with mobility. Risk assessments are in place for any identified areas of risk and the staff confirmed that risk assessments are evaluated regularly. Though as previously stated none of the service users are able to use speech to communicate but staff have built up a good knowledge of service gestures and body language. To assist them in making choices and decisions. This was evident from observations we made during our visit and this is also reflected in the activities plans that staff have developed with service users. And for person staff had arranged an advocacy visit prior to them moving into the home. Midmoor Road (19) DS0000015773.V372941.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 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users access community facilities and take part in activities that they like. This ensures are assisted to lead active and fulfilling lifestyles. Routines in the home are service user focussed and meet individual needs. Service users receive a healthy, varied and attractively presented meals in a relaxed and unrushed manner and where required special diets are also provided. This ensures the health and well being of the service users. EVIDENCE: Staff support service users to take part in and access local community facilities as well as participating in activities inside the home. Some service users attend a local day centre during the week. Midmoor Road (19) DS0000015773.V372941.R01.S.doc Version 5.2 Page 14 At the time of our visit the service users had been taking part in an arts and craft session where they were making items for a Halloween party. Two of the service users were going out in the evening to see Cinderella on ice at the Empire theatre and one person went out swimming in the afternoon. Each person has their own individually designed activities chart and this lists the activities that they are taking part in on a daily basis. One person had been to see Sunderland football team play and then went for a pub lunch. It was evident that the service users take part in a wide range of activities. The home also has a sensory room which service users enjoy using. Staff encourage service to participate in baking, craft activities and listening to music inside the home. In discussion with staff it was confirmed that service users couldn’t tell staff what they like to eat. Therefore staff have compiled lists of what people have eaten in the past and whether they have given a sign that they enjoyed this. From this they have complied menus that are changed every four weeks to ensure a good variety of meals are offered. Should a service user display signs of not liking a meal then staff will offer an alternative. One person has to have their food prepared in a certain way to assist them with eating and swallowing. Staff have obtained special food moulds so that when their food is blended it can be shaped in the moulds. This ensures that food is presented that looks appetising. The staff team includes a person known as an “enabler” who is responsible for organising the activities and they assist staff when helping service users to take part in activities. In discussion with staff it was confirmed that every service user had been on holiday this year. And holidays had been carried out to Blackpool, Kielder and Scotland. It was positive to note that staff organise activities and holidays on an individual basis and this makes it personal for the service user. Two service users have regular contact with relatives and for others contact is maintained where possible. Midmoor Road (19) DS0000015773.V372941.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. Staff are good at caring for people and making sure service users receive the right healthcare. However some matters relating to medication recording require updating. EVIDENCE: Individual care plans that relate to health are up to date and include a range of information about other health professionals who are involved in the care process. Records are available to show when service users visit the G.P. These records also confirm how staff have made appropriate referrals to specialist health services due to changes in service users behaviour. For example the speech and language department, the physiotherapist and the dietician. Discussion held with staff confirmed that they provide as much help as each person needs. Midmoor Road (19) DS0000015773.V372941.R01.S.doc Version 5.2 Page 16 The staff have a very good understanding of peoples physical health and how the person’s learning disability affects them. And though some changes in general health are not always fully recorded in the care plan. There is evidence in other records to confirm that staff responds quickly to any change in health needs. All of the equipment that is necessary to support individual service users has been obtained and all staff have received training in the use of this equipment. None of the service users manage their own medication and an agreement is in place in each service users file for staff to administer them on their behalf. All staff has undertaken accredited training in the safe handling of medicines. The medication administration records had an unexplained gap for one day for one person where it could not be confirmed whether or not they had received their prescribed medicines. This was discussed with the person in charge. Each service user has a key worker assigned and also a co key worker who is responsible for carrying out many of the personal tasks associated with their individual care. Staffing ratios also take into account gender issues when dealing with personal care tasks. Discussion held with staff and observations made confirmed that the staff have a good understanding of service users. They also have a very positive approach to their work ensuring that the service user comes first and that their rights and responsibilities are recognised in the daily lives. Midmoor Road (19) DS0000015773.V372941.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. A clear accessible complaints procedure gives service users and their relative’s confidence that they will be listened to and taken seriously. And staff has a good understanding of local adult protection procedures, which helps to ensure the protection of service users from abuse. EVIDENCE: The complaints procedure is produced in pictorial format to make it more accessible for people using the service. The home has a policy and procedure in place informing of the process should any complaints be received into the home. No complaints have been received into the home since our last visit. The complaints procedure was last updated in 2004 and requires some updating. It currently includes reference to the previous owners and it also makes reference to 2 commission offices that are no longer open. As previously stated in this report service users are unable to communicate using speech therefore they are not able to say if they are dissatisfied with anything. Midmoor Road (19) DS0000015773.V372941.R01.S.doc Version 5.2 Page 18 However staff make a point of observing for any changes in behaviour as a way of measuring whether someone may be upset. And should this be the case then they take appropriate action. All staff have received training from social services in safeguarding adults and are clear about how service users are to be protected from potential abuse. Staff knows how and to whom an alert has to be made if they have concerns and one incident that was reported by staff this year. Was dealt with quickly using the appropriate safeguarding procedures. This ensures that service users are protected from abuse. Midmoor Road (19) DS0000015773.V372941.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): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is comfortable and well maintained, and is kept clean and free from infection. This ensures that service users have a nice environment in which to live. EVIDENCE: Midmoor Road is pleasantly decorated with good quality furniture and fittings in keeping with the age and lifestyle choices of service users. Suitable Laundry and drying facilities are in place so that service users clothes can be cleaned and laundered on the premises. Policies and procedures are in place to deal with the control of infection and staff ensure that the building is kept clean. Midmoor Road (19) DS0000015773.V372941.R01.S.doc Version 5.2 Page 20 There is a well-equipped sensory room that is fitted with comfortable chairs, lighting, décor and music. And service users use this room as a room to spend time in relaxing. Most of the service users are dependent upon the use of specialised equipment and where necessary their rooms are equipped with specialised hoists to assist with mobility. There were no noticeable hazards however some of the doors leading to storage areas were open when the signs clearly said “ keep locked” and similarly some doors were wedged open. This potentially compromises fire safety in the home and this was discussed with the person in charge. There were no defects to the premises but there are some minor matters that require addressing in order to maintain the good physical standards and these to were discussed with the person in charge. Midmoor Road (19) DS0000015773.V372941.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 receive sufficient training to support them in their work, to ensure residents receive good quality care, and current staffing levels make sure service users have a number of opportunities to go out. Robust recruitment procedures are in place to prevent unsuitable people being employed. EVIDENCE: Staff records are held centrally at the “Trusts” main office therefore staff files were not viewed as part of this visit. However previous inspections of the service have confirmed that the service has a robust recruitment procedure in place that highlights the process to be followed. And this involves the taking up of necessary references, a full employment history and a criminal record bureau check. Midmoor Road (19) DS0000015773.V372941.R01.S.doc Version 5.2 Page 22 Good staffing ratios are in place and this enabled service users to have a number of opportunities to access activities in the community. In discussion with staff it was confirmed that they had received training in infection control and fire safety. The assistant team leader is in the process of arranging training in first aid. The annual assessment of training needs for the last 12 months was not carried out due to the manager having been on long-term sick leave. However the assistant team leader who is ensuring that all staff complete updated mandatory training is now addressing this. In discussion with staff it was clear that they had built up a good knowledge base of individual services needs. They have developed ways of communicating using methods other than speech. And are also working with other professionals as part of the care process. This has ensured that staff have continued to develop their competencies in the work and also follow best practice. Midmoor Road (19) DS0000015773.V372941.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): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall management systems are effective to ensure that the service is run in the best interests of the service users. EVIDENCE: The service does not currently have a registered manager and the person who was going forward to be registered has been on long - term sick leave. This person has only recently returned from sick leave but has not yet commenced work in the home. Midmoor Road (19) DS0000015773.V372941.R01.S.doc Version 5.2 Page 24 The assistant team leader who has a range of experience is managing the service and has been since January of this year. The assistant team leader is continuing to improve the service and provide an increased quality of life for residents. She is ensuring that staff receive updated training and are supported with their work. Records are being updated and standard documents that have been in use since the home originally opened are being updated to reflect the current owners name and address. Thorough procedures are in place for dealing with any accidents in the home and good records are maintained. All staff receive appropriate fire instruction training and take part in fire drills and records are in place to confirm this. And all staff received updated fire training in October by the “Trusts” fire officer. Good health and safety procedures are in place particularly with safe bathing. And staff ensure that hot bathing water is always checked before some is bathed. This ensures that no one is at risk from scalding. Quality assurance systems are in place and the operational manager continues to visit the home on a monthly visit to carry out various audits. In addition to offering support to the assistant team leader. The home manages residents’ finances on their behalf and systems are in place to record transactions. Checks show that records are up to date and accurate. Previous inspection visits have confirmed that the home continues to gather service users and their relatives’ views as part of the homes quality monitoring system. Questionnaires are sent out on a yearly basis and the information gathered from questionnaires is collated and shared with staff with a view to sharing good practice and highlight any areas of poor practice. Midmoor Road (19) DS0000015773.V372941.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 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Midmoor Road (19) DS0000015773.V372941.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 YA6 Regulation 15 Requirement Individual care plans must be updated as part of the ongoing assessment and review of service users needs. This will ensure that staff are following consistent practices when meeting service assessed needs. A written record must always be kept if a service user is not given their medication. This will ensure that good practice guidelines are followed. (Immediate) Doors that have been identified as fire doors on storage cupboards must be kept locked. And no fire door should be wedged open with any device unless the fire authority approves it. This will ensure that the safety of service user and staff is not compromised. (Immediate) Timescale for action 31/01/09 2. YA19 13 (2) 30/10/08 3. YA42 23 (4) (a) 30/10/08 Midmoor Road (19) DS0000015773.V372941.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA5 YA22 Good Practice Recommendations Individual contracts and other records in use should be updated to include reference to the “Trust”. So that people are clear as to whom the owners are. The complaints procedure leaflet should be updated to include reference to the owners. And also to include the correct address for the commission. Midmoor Road (19) DS0000015773.V372941.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 Midmoor Road (19) DS0000015773.V372941.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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