Care Home: St Stephen`s Court

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What the care home does well Service users, where able, described good relationships with the staff and said they were all polite and helpful.Staff were friendly and relaxed and showed a good understanding of their needs. Arrangements for service users to maintain contact with their family and friends are good. Meals are varied, well-balanced, offering a good choice and nutritious food at all meals. All of the those spoken to were pleased with the quality and choice available. Meals were seen as a relaxed and social occasion. Two service users have a percutaneous endoscopic gastrostomy (peg) feed. The home is staffed with a skilled, consistent and trained staff team giving security to service users. The staff had a good understanding of service users individual needs. More than fifty percent of staff are qualified to National Vocational Qualification in Care level 2 (NVQ) or above providing service users with a trained, skilled staff team. The service users were very complimentary about the staff. The facilities within the home for service users are very good; they have access to the Internet, sensory room, hydro pool and an attractive enclosed garden. What has improved since the last inspection? New lounge chairs have been purchased. The hydrotherapy pool has been fitted with an overhead hoist. A new manager has recently been appointed. CARE HOME ADULTS 18-65 St Stephen`s Court Brunel Terrace Newcastle upon Tyne Tyne and Wear NE4 7RL Lead Inspector Jim Lamb Key Unannounced Inspection 10th September 2008 10:00 St Stephen`s Court DS0000069987.V371753.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 St Stephen`s Court DS0000069987.V371753.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. St Stephen`s Court DS0000069987.V371753.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Stephen`s Court Address Brunel Terrace Newcastle upon Tyne Tyne and Wear NE4 7RL 0191 273 0303 0191 373 3659 nevillesx@aol.com 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) Durham Care Line Ltd t/a Careline Lifestyles Ms June McKenzie (Not yet registered) Care Home 10 Category(ies) of Learning disability (10), Physical disability (10) registration, with number of places St Stephen`s Court DS0000069987.V371753.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 with nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories Physical Disability - Code PD, maximum number of places: 10 2. Learning Disability - Code LD, maximum number of place: 10 The maximum number of service users who can be accommodated is 10. 30th August 2007 Date of last inspection Brief Description of the Service: St Stephens Court is a home registered to provide personal and nursing care to ten young adults who are physically dependent, learning disabled or require rehabilitation following brain injury or neurological disorders. The home provides permanent and respite places. The home was purpose built and provides care over three floors accessed by a lift. Situated in the west of the city of Newcastle there are limited local facilities. Residents have their own bedrooms, which are well furnished and have ensuite toilet, some also have shower facilities. Bathrooms and lavatories are equipped with specialist equipment to assist physically dependent people. There is one large lounge, dining area, quiet room, sensory room, spa/hydrotherapy pool, domestic kitchen and laundry. There is an accessible garden. Computers, plasma screens and internet access are available in all rooms. A Statement of Purpose and service user guide are available at the home for residents who are interested in coming to stay at the home. The guides describe the services and facilities provided by the home and inspection reports would be made available at the home detailing the quality of care provided. Fees payable for living at the home vary according to the individual package and currently range from £800 to £1600 per week. St Stephen`s Court DS0000069987.V371753.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 home is 2 star. This means that the people who use the service experience good quality outcomes. 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 the service are being put at significant risk of harm. In future is a requirement is repeated, it is likely that enforcement action will be taken. How the inspection was carried out Before the visit: We looked at: • Information we have received since the last visit. • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on 10/09/08 During the visit we: • • • • • • Talked with people who use the service, staff, the manager & the area co-ordinator for the service. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit. We told the manager/provider what we found. What the service does well: Service users, where able, described good relationships with the staff and said they were all polite and helpful. St Stephen`s Court DS0000069987.V371753.R01.S.doc Version 5.2 Page 6 Staff were friendly and relaxed and showed a good understanding of their needs. Arrangements for service users to maintain contact with their family and friends are good. Meals are varied, well-balanced, offering a good choice and nutritious food at all meals. All of the those spoken to were pleased with the quality and choice available. Meals were seen as a relaxed and social occasion. Two service users have a percutaneous endoscopic gastrostomy (peg) feed. The home is staffed with a skilled, consistent and trained staff team giving security to service users. The staff had a good understanding of service users individual needs. More than fifty percent of staff are qualified to National Vocational Qualification in Care level 2 (NVQ) or above providing service users with a trained, skilled staff team. The service users were very complimentary about the staff. The facilities within the home for service users are very good; they have access to the Internet, sensory room, hydro pool and an attractive enclosed garden. What has improved since the last inspection? What they could do better: To enable all potential new service users to understand the contents of the service user guide, information should be made available in a pictorial format and on audiotape. Care plans should also be made available in a user-friendly format, pictorial plans will enable service users to participate and understand the process much more easily. Each service users should be provided with a detailed social care plan, and these should clearly identify all of their social needs and how these will be met. St Stephen`s Court DS0000069987.V371753.R01.S.doc Version 5.2 Page 7 There must be enough staff on duty at all times to meet the service users holistic care needs. The care needs of service users must not be compromised by staff having to take on additional cleaning, cooking and laundry tasks. Additional staff must be employed to ensure that the service users personal health and social care needs are fully met at all times. (The Regional Care Co-ordinator agreed to improve staffing levels, and will submit a revised staffing rota to CSCI within 7 days.) To ensure that the manager has the opportunity to manage the home properly, the manager’s hours should include an appropriate amount of supernumerary hours. Revised staffing levels rota submitted from 22/9/08 The manager has been allocated 22 supernumerary hours. Care staff hours have also been increased slightly, as have catering staff hours at weekends. It was noted that one of the qualified nursing staff that is contracted for 40 hours, was on loan to another unit within the company. This is a temporary arrangement and she will be retuning to the home soon. On her return, this will improve the homes staffing levels. The new rota did not identify any additional domestic or laundry hours. The inspector discussed this issue with the regional care co-ordinator, and it was agreed that she would consider employing domestic/laundry staff. 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. St Stephen`s Court DS0000069987.V371753.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 St Stephen`s Court DS0000069987.V371753.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, 3 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users are provided with enough information about the service to enable them to make a choice about where they want to live. EVIDENCE: The care records for two service users were examined. These showed that the service makes sure that a full assessment of a new service users needs is carried out by the person’s social worker before they come into the home. The manager also carries out her own assessment, to be doubly sure that the home can meet all of the new person’s needs. More detailed assessments are carried out once the new service user has come into the home. These include assessments of risk; of nutritional needs; of social needs; of moving and handling needs and of behavioural needs. As a result of all these levels of assessment, the manager can clearly demonstrate that all her service users are in a home that can give them the care that they need. St Stephen`s Court DS0000069987.V371753.R01.S.doc Version 5.2 Page 10 All are provided with a contract explaining the homes terms and conditions, and fees. To ensure that all prospective service users fully understand information about the home, and to help them to make a choice about where they want to live. It is recommended that the home implements a pictorial service users guide, and also provide information on audiotape. St Stephen`s Court DS0000069987.V371753.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. The promotion of health care is taken seriously, and service users have their personal needs met in the way that they prefer. EVIDENCE: There are comprehensive assessments in the service users’ care plans. There is also a comprehensive risk assessment of service users. There are advocacy arrangements, as well as family input to represent service users. Care plans and risk assessments are drawn up with service users and their relatives. Plans are amended and reviewed on a regular basis. St Stephen`s Court DS0000069987.V371753.R01.S.doc Version 5.2 Page 12 Some information within the care records was a little disjointed and not easily accessible. The new manager has some excellent ideas about how to improve the current systems, and intends to implement these in the near future. Consideration should also given to implement pictorial care plans, and this will make it easier for service users to become more involved, and fully understand the care plan process. Once care plans and risk assessments have been drawn up, these should be agreed and then signed by service users, or their representatives. There are systems in place that will ensure that the placement and the service users plans are reviewed annually. These involve the care managers and the service users representatives. Three service users confirmed that their privacy and dignity are respected at all times. Service users’ said that they are able to make decisions for themselves, and that they are happy with the care that they receive. One said “I like it here, it is a good place for me, the staff are kind, and they take me into town and other places that I like to visit”. St Stephen`s Court DS0000069987.V371753.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, 14, 15, 16 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service users are not offered a lifestyle, which includes sufficient social contact, activities and choice. EVIDENCE: Each service user has a social skills assessment carried out. These are separate from the service users care records. It is recommended that specific social care plans be implemented; these should include each service users hobbies, interests, education, community links and social contacts. These should clearly identify how staff will meet each St Stephen`s Court DS0000069987.V371753.R01.S.doc Version 5.2 Page 14 person’s social needs. Service users are supported and encouraged to be in control of their own lives. However appropriate activities outside of the home, and service user choice is restricted because of the current staffing levels. The home does not have its own transport, and relies on public transport for outings. The provider must also explore and arrange appropriate holiday destinations for those service users who would like the opportunity to go away on holiday. All service users are supported to maintain very close links with their families. They can choose who they want to see and when. The Home’s menus are based on the known likes and dislikes of the service users. At least two hot meals are provided each day. The menus have been drawn up with help from three service users, and they are varied and well balanced. All those spoken to said that the meals were very good and that they were always offered a choice. The service employs a full time cook, on her days off, support staff provide the catering. The service co-ordinator confirmed that when the support staff are providing the catering, they are always supernumerary to the rota, however the staff rota examined did not indicate this. The kitchen was clean and well organised, and stock levels were good. It is recommended that service users spiritual needs and beliefs are assessed, and provide them with opportunities to fulfil their spiritual needs. St Stephen`s Court DS0000069987.V371753.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 the service. Each person has an individual assessment of his or her personal health needs, and has a care/goal plan in place to meet those needs. EVIDENCE: Service users care records showed that they have access to external health care services. G.Ps visit when necessary. Service users are referred for specialist health care if appropriate. All service users receive regular health care checks. The service employs two physiotherapists and service users benefit greatly from this support. Each person has his or her own ‘Personal Health Information’ file. This contains professional health assessments, correspondence, and records of St Stephen`s Court DS0000069987.V371753.R01.S.doc Version 5.2 Page 16 contacts with health professionals. It demonstrated that all aspects of a person’s physical and mental health are taken seriously and are properly met. The manager said that the service receives excellent support from the local Challenging Behaviour Team, and the Person Centred Planning Team. Skin viability is carefully monitored, and those at risk have the correct equipment in place to minimise potential skin problems. The District Nursing Service also provides good advice and support, should skin problems arise. Staff who have completed relevant training administers medication. A sample of medication records was examined. These include photographs for identification purposes. Clear directions were recorded and each dose of medication was signed for, or a code entered to verify the reason not given. No controlled drugs are currently prescribed, should this change, appropriate procedures are in place. One service user said, “Medication is supplied correctly and at the right times”. Privacy and dignity issues are built into the home’s policies and procedures, staff training and supervision sessions. All personal care and medical examination/treatment is carried out in private. The dispensing pharmacist offers good support and advice. St Stephen`s Court DS0000069987.V371753.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 home has good, complaint and protection system, service users are safe and their views are listened to and acted upon. EVIDENCE: There is a complaints procedure. It contains details of how to contact the CSCI to make a complaint, if complainants are not happy with the homes investigation and response. The procedure is not written in a way that ensures service users fully understand its contents. Again a pictorial procedure would enable service users to understand its contents. Two service users with full capacity said that they had been given copies of the procedure and that staff listened to their concerns and always dealt with them fairly. The home keeps a record of complaints. The home has a Whistle Blowing policy, the Local Authorities Vulnerable Adults procedures, and a copy of the Department of Health’s document, “NO SECRETS”. Staff are aware of these procedures and have easy access to them. St Stephen`s Court DS0000069987.V371753.R01.S.doc Version 5.2 Page 18 Since the last inspection visit, there have been two complaints received, these were investigated immediately and easily resolved. Safeguarding adults training is ongoing for all staff. Service users can deposit cash for safekeeping, and records are kept of accounts. A sample of personal finances records was examined. Transactions were appropriately recorded and had two signatures for each entry. There was plenty of evidence of personal spending. Receipts are obtained for purchases and numbered to cross-reference to the transaction. Weekly checks of balances and cash are carried out. St Stephen`s Court DS0000069987.V371753.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, 25, 26, 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable, clean, safe and pleasant environment for those living there. EVIDENCE: The home was clean, well decorated and well maintained. The grounds were tidy, safe, attractive and accessible. The fire service and the environmental health department had made visits to the home prior to its registration. Recommendations made by these organisations had been met. The home has an appropriate amount of sitting, recreational and dining space. There are enough rooms for a variety of activities to take place. St Stephen`s Court DS0000069987.V371753.R01.S.doc Version 5.2 Page 20 New lounge chairs have been purchased. The communal areas: walls and doors are all decorated in the same bright yellow colour, although attractive, some thought should be given to using different colours schemes in various parts of the home. Research indicates that using different colours can benefit service users who have orientation difficulties. Service users also have access to a computer and can access the Internet. Service users can see visitors in private in their own rooms. Furnishings and fittings were domestic in design and in very good condition. Lighting was bright and domestic in design. All doors have privacy locks and room sizes exceed the minimum required. There is space on either side of beds when necessary, to enable access for carers and specialist equipment. The bedrooms are personalised, and each room is provided with a wallmounted plasma TV. Service users’ bedrooms have top opening windows. The rooms were centrally heated and the heating level could be controlled within each bedroom. The home also has a hydrotherapy pool, and since the last inspection visit, an overhead hoist has been installed to enable those with a physical disability to use the pool. There was emergency lighting throughout the home. Water is stored at over 60°C. Valves at water outlets ensure water is provided close to 43°C to prevent scalding. The home was clean and free from offensive odours. The washing machines have the specified programme to meet disinfection standards. St Stephen`s Court DS0000069987.V371753.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 adequate. This judgement has been made using available evidence including a visit to this service. There is a good match of well-qualified staff, however there are insufficient numbers of staff to meet the holistic needs of the service users. EVIDENCE: Staff levels on the day of the inspection were not sufficient to meet the holistic needs of the service users. Three service users require nursing care, and need 2 staff for the majority of their care needs Two service users have a (PEG) feeding system. Four other service users can display challenging behaviours, and need close supervision. Another needs to be supervised outside when smoking, usually up to 3 cigarettes per hour. St Stephen`s Court DS0000069987.V371753.R01.S.doc Version 5.2 Page 22 The numbers of staff were on duty: 4 staff between 8am and 3pm, 3 sometimes 4 staff between 3pm and 8pm, with 2 staff between 8pm and 8am. The manager’s hours are included in the staffing hours. A qualified nurse is on duty at all times and they are also included in these numbers. No designated domestic or laundry staff are employed. Therefore care staff carry out these additional duties. The inspector discussed the staffing levels with Anita Ennis Regional Care Coordinator. She agreed to improve the staffing levels, and agreed to submit a revised staffing rota to CSCI within 7 days. She will also organise some supernumerary hours for the manager. She said that the head office in Durham carried out the majority of administration for the home. All staff were over 18 years of age and those left in charge were at least 21. The training needs of the staff are identified in supervision and appraisal sessions. The homes training programme meets the National Training Organisation requirements for the first six months. Staff receive at least three days paid training each year. The manager confirmed that the service has a rigorous staff recruitment and selection process to ensure that all appropriate checks and references are in place prior to employment. Currently, all recruitment records, applications, references, police checks, proof of identity etc, are held in the company’s head office in Durham. Therefore the inspector was unable to verify that appropriate checks, and processes had been implemented prior to employing new staff. The Regional Care Co-ordinator, said that she will arrange for staff records to be transferred to the home. The service has a good staff training and development programme in place. All statutory training was up to date and 50 of the staff team has completed NVQ level 2/3. St Stephen`s Court DS0000069987.V371753.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. The manager is new; she has the skills and experience to manage the home properly. EVIDENCE: The manager has been in post for 6 weeks, she has the appropriate qualifications, experience and skills necessary to manage the service. She is not yet the approved registered manager, however she has many years experience, she is a qualified learning disabilities nurse, and has D32/33 teaching qualification. St Stephen`s Court DS0000069987.V371753.R01.S.doc Version 5.2 Page 24 Staff were clear about their responsibilities, they were friendly, and had good knowledge of the service users needs. Service users are told when inspections take place and there are copies of reports available for relatives and others to see. A quality system is in place to monitor the quality of the service provided. This involves gaining feedback from service users, relatives and professionals involved with the home. The outcomes will be published and made available to all prospective service users. The manager intends to implement an annual development plan. There is a health and safety policy and a range of associated procedures. Staff receive training in health and safety and safe working practices (fire safety, moving and handling, first aid, food hygiene, and infection control). The regional care co-ordinator confirmed that servicing and maintenance agreements are in place for facilities and equipment. This is a new build and all facilities and equipment are under construction guarantee. All fire safety checks; tests and instructions to staff are conducted at the required frequency and recorded. St Stephen`s Court DS0000069987.V371753.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 3 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 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 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 2 13 2 14 X 15 2 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 St Stephen`s Court DS0000069987.V371753.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES 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. 2. Standard YA13 Regulation 16(2)(m) Requirement Sufficient individual activities and opportunities for social interaction, inside and outside the home must be provided for all service users. Outstanding since 01/12/07 3. YA33 18(1)(a) 18(3) Sufficient support staff to be on duty at all times to meet the assessed holistic needs of service users. Laundry/domestic staff to be employed to enable support staff to meet the care needs of all service users. 01/10/08 Timescale for action 01/10/08 St Stephen`s Court DS0000069987.V371753.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. 3. 4. 5. 6. Refer to Standard YA14 YA28 YA1 YA14 YA6 YA37 Good Practice Recommendations Provide service users with the opportunity to go on holiday outside the home, which they help to choose and plan. Consider using various colour schemes around the home, this may help those with orientation difficulties. Provide prospective service users with a pictorial service user plan. Individual detailed social care plans must be implemented for all service users. Individual care plans must be in a format that enable service users to be fully involved, The provider must submit an application for the registration of the new manager to CSCI. St Stephen`s Court DS0000069987.V371753.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 St Stephen`s Court DS0000069987.V371753.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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