Care Home: Stanley Burn Care Centre

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What the care home does well Staff were kind and considerate when helping people who use the service. People who use the service and relatives explained the admission process; this usually includes a visit from the manager. This helps new people identify their own needs and enables staff to know how to meet their needs during their stay. The service gives good support to enable individuals to make decisions and participate in the running of the home. The service gives good support to enable individuals to identify and access health care. The service gives good support to enable individuals to maintain and develop personal and family relationships. The home and organisation has good systems to enable people who use the service to share their views and they continue to look at ways of involving people and improving individualised services. There is a complaints procedure, and in addition the views of people who use the service are actively sought. People who use the service felt their views were listened to and acted upon. People who use the service said, and it was seen, that staff were kind, considerate and supportive. People who use the service and their relatives commented "Quite happy" "My husband is extremely well cared for at Stanley Burn Care Home" "The home is warm, comfortable" "Every care is taken to see that the residents are warm, clean and comfortable". Supporting health and social care professionals commented "Stanley Burn management has a very established and good working relationship with a variety of professionals in the mental health team based in Hexham. It is credit to the hard work and dedication provided by them that I hear from relatives how confident they are in the care provided to their loved ones" "Generally a good home, well managed". What has improved since the last inspection? CARE HOMES FOR OLDER PEOPLE Stanley Burn Care Centre Station Road Wylam Northumberland NE41 8JA Lead Inspector Mary Blake Key Unannounced Inspection 2nd & 8th May 2008 09:00 X10015.doc Version 1.40 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 Stanley Burn Care Centre DS0000063750.V363078.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 Older People. 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. Stanley Burn Care Centre DS0000063750.V363078.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stanley Burn Care Centre Address Station Road Wylam Northumberland NE41 8JA 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) 01661 - 853298 01661 854293 sbeuropeancare@aol.com www.europeancare.co.uk European Care (England) Ltd Ms Andrea Selby Care Home 40 Category(ies) of Dementia - over 65 years of age (22), Old age, registration, with number not falling within any other category (18) of places Stanley Burn Care Centre DS0000063750.V363078.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 3rd May 2007 Brief Description of the Service: Stanley Burn Care Centre accommodates 40 people in a two storey detached property. It is set in a quiet residential area on the outskirts of the village of Wylam. The home is on two floors with a passenger lift to all levels. There are a variety of aids and adaptations to allow residents to move freely around their part of the home. All of the bedrooms are single, with twenty one having ensuite facilities and communal bathing and toilet facilities are situated around the home. There is sufficient communal lounge and dining space. The home is close to local amenities and transport networks. Stanley Burn Care Centre is registered to provide residential care for frail older people and older people with dementia. The statement of purpose and resident guide, which includes the last inspection report, is available at the front entrance and individual copies are provided to residents The fees range from £419 to £500 per week. Stanley Burn Care Centre DS0000063750.V363078.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means that the people who use this service experience good quality outcomes. An unannounced visit was made on the 1st May 2008 with a further planned visit on the 8th May 2008. The Manager was present throughout the inspection. Before the visit: We looked at: • Information we have received since the previous inspection of 3rd May 2007. • How the service dealt with any complaints and concerns since the previous inspection. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service and their relatives, staff and other professionals, including surveys. • The Annual Quality Assurance Assessment (AQAA), which is a selfassessment document, was well completed and returned to CSCI. During the visit we: • Talked with people who use the service, relatives, staff and the manager. • Looked at information about the people who use the service and how well their needs are met, • Looked at other records which must be kept, • Checked that staff had the knowledge, skills and training to meet the needs of the people they care for, • Looked around the building/parts of the building to make sure it was clean, safe and comfortable. • Checked what improvements had been made since the last visit • Sent “have your say” questionnaires out to people who have used or had interest in the home, eighteen of which were returned to us. • Undertook an assessment of how/if the care needs of people with dementias are being met, by using the short observational framework for inspection tool (SOFI). We told the manager what we found. Stanley Burn Care Centre DS0000063750.V363078.R01.S.doc Version 5.2 Page 6 What the service does well: Staff were kind and considerate when helping people who use the service. People who use the service and relatives explained the admission process; this usually includes a visit from the manager. This helps new people identify their own needs and enables staff to know how to meet their needs during their stay. The service gives good support to enable individuals to make decisions and participate in the running of the home. The service gives good support to enable individuals to identify and access health care. The service gives good support to enable individuals to maintain and develop personal and family relationships. The home and organisation has good systems to enable people who use the service to share their views and they continue to look at ways of involving people and improving individualised services. There is a complaints procedure, and in addition the views of people who use the service are actively sought. People who use the service felt their views were listened to and acted upon. People who use the service said, and it was seen, that staff were kind, considerate and supportive. People who use the service and their relatives commented “Quite happy” “My husband is extremely well cared for at Stanley Burn Care Home” “The home is warm, comfortable” “Every care is taken to see that the residents are warm, clean and comfortable”. Supporting health and social care professionals commented “Stanley Burn management has a very established and good working relationship with a variety of professionals in the mental health team based in Hexham. It is credit to the hard work and dedication provided by them that I hear from relatives how confident they are in the care provided to their loved ones” “Generally a good home, well managed”. Stanley Burn Care Centre DS0000063750.V363078.R01.S.doc Version 5.2 Page 7 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. Stanley Burn Care Centre DS0000063750.V363078.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Stanley Burn Care Centre DS0000063750.V363078.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions to the home are appropriately managed and people who use the service know how their needs will be met. EVIDENCE: Stanley Burn Care Centre has a Statement of Purpose and a Service Users’ Guide to provide people who use the service and potential service users with information about the home. The care plans all have pre-admission assessments. These had been carried out by either the manager or by a senior member of the staff team. Stanley Burn Care Centre DS0000063750.V363078.R01.S.doc Version 5.2 Page 10 The people who use the service also have a care management assessment, which is provided to the home on admission. An individual care plan is produced from these documents. The home is not registered for, and therefore does not provide, intermediate care. As part of the preadmission process people who use the service had visited the home, including with their relatives if they wished, had meals, stayed overnight and met other people who use the service and the staff. In this way they got to know the home before moving in. People who use the service commented, “I had a chance to look around and bring my things in”. Health and social care professionals commented, “Liaises with a range of professionals to ensure all care needs are met and any education/advice is sought” “Supports relatives in adjusting to their loved ones entering care”. Stanley Burn Care Centre DS0000063750.V363078.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive care and support that is well planned and takes into account their diverse needs whilst promoting their privacy and dignity. EVIDENCE: All people who use the service have a care plan which includes an assessment of their needs and a plan of how these should be met. European Care is currently reviewing the format and structure of these plans; documentation includes risk assessment for fall prevention, moving and assistance as well as clinical areas such as continence assessment. The new care plans were still being implemented. Those that had been completed were to a good standard, which reflected the health needs of the people who use the service. The care plans were up to date Stanley Burn Care Centre DS0000063750.V363078.R01.S.doc Version 5.2 Page 12 and contained the information to assist the staff to care for the people who use the service. People who use the service and their relatives commented, “All basic needs are met. In addition, the staff are adaptable enough to be able to meet some, if not most of mums little personal requests” “the personal touch is always there, for residents and relatives alike” “Occasional minor instances have occurred: e.g. wet or too tight footwear needed changing”. The people who use the service receive personal support the way they prefer and their physical and emotional health needs are met. Staff were confident when giving care and are supported by effective training in areas such as moving and handling. The individual health needs of people who use the service are identified and people are supported to access community health services such as doctor, district nurse, dentist, and optician. All people who use the service have an annual health check. Residents commented “I always see my doctor on request”. Relatives commented, “Andrea keeps me fully informed about mum. When necessary they use phone or email for this” “Very happy with the improvement in my fathers health and continuation of same since becoming a resident at Stanley Burn” “Every care is taken to see that the residents are warm, clean and comfortable” “The staff always promptly ask my husbands G.P to come when they think it is necessary”. Health and social care professionals commented, “I can say that staff are most vigilant in responding to any physical or mental health changes in the clients I have at the home. They will act confidently and assertively with a range of professionals if they believe a problem is not receiving the necessary attention” “screening well for causes of increased confusion” “Individualising care including moving people between units of the home as appropriate” “Addresses physical ailments very promptly” “Supports end of life care within the home helping clients die with dignity and supporting their relatives”. Staff training has been undertaken to provide awareness and additional support for health related needs. People who use the service are protected by the homes policies and procedures in dealing with medicines. There is good liaison with supporting professionals. A full medication audit was not carried out but case tracking and discussion of medication administration showed that staff were knowledgeable and skilled in this area. People who use the service feel their privacy and dignity is respected and that they are listened to and what they say is acted upon. Stanley Burn Care Centre DS0000063750.V363078.R01.S.doc Version 5.2 Page 13 Relatives commented, “They (staff) are always efficient and caring about this, whilst respecting privacy as appropriate” “Maintaining residents dignity and individuality (most staff are very good at this)”. Supporting health and social care professionals commented, “Staff knock on doors before entering, ask peoples preferences etc. Where possible choices are given. Clients are taken out shopping, offered choices in their rooms e.g. décor, furniture etc. This may take time to arrange but usually does happen”. Staff receive training that helps them to make sure that everyone is treated with respect, and as an individual. Staff help people make their own decisions and provided information and assistance when it is needed. Staff were friendly toward the people who use the service and were attempting to engage them in conversation. Staff seek permission prior to entering individual rooms and were communicating well with people. People who use the service were observed to move freely around the home. Stanley Burn Care Centre DS0000063750.V363078.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are part of the local community and participate in leisure activities. They are supported to retain personal and family relationships and their rights are respected in their daily lives. EVIDENCE: People who use the service are offered the opportunity to join in a range of social and leisure activities. They have the opportunity to use community facilities for leisure activities e.g. pubs, cafes, shops etc. They are offered the opportunity to experience new activities and leisure pursuits as well as supported where necessary to continue with hobbies and interests. Social needs of the people who use the service are assessed and then plans made to make sure that the people living in the home live fulfilled lives taking into account their level of dependency. The Manager had ensured that all Stanley Burn Care Centre DS0000063750.V363078.R01.S.doc Version 5.2 Page 15 recorded information is reviewed and summarised on a monthly basis. People who use the service and their families raised the lack of activities. People who use the service commented, “I usually dont take part. But do like it when the comedian comes to the home”. Relatives commented “It would be of benefit if there was more motivation” “The home does have some craft work usually once a week but more is needed to break up the ‘sitting around watching television’ a lot of the time” “Someone to sing or play an instrument now and again would be helpful I think” “Maybe with the summer, more outings could be enjoyed” “A telephone extension is not always available or convenient to use by the residents. Friends or relatives need to be able to talk to residents in relative comfort and privacy. Im sure Andrea has something in hand for this, as I brought it up in mums appraisal interview” “More outside help should be brought in for regular activities to keep residents minds and bodies in use - e.g. exercise both physical and mental”. Health and social care professionals commented “As always in residential homes (in my experience) I find staff very good at care giving, less so at social events/organisation” “A more varied programme of social activities may benefit those clients who are not able to seek out company or move around easily to access alternative sources of stimulation”. The recent appointment of a social activities coordinator may help develop and support the social interests of people who use the service. Staff assist and encourage people who use the service to maintain family links and previous friendships, respecting the individual’s wishes. Staff seek permission prior to entering individual rooms and were communicating well with people. People who use the service were observed to move freely around the home. Relatives commented “my mother, and I presume some other residents are the same, is virtually incapable of making life choices other than where to sit of whether to get up and walk about and other such small decisions. She is, however, encouraged to make these decisions”. Health and social care professionals “Relatives are encouraged to play an active part in their loved ones new lifestyle”. The four weekly menu is currently changing to the summer choices. People who use the service were positive about the choice and range of food available. The dining arrangements had improved with new décor, furniture, carpets and furnishings in two dining rooms. Mealtimes were seen to be a relaxed and sociable occasion, with nicely laid tables and with good staff support. Stanley Burn Care Centre DS0000063750.V363078.R01.S.doc Version 5.2 Page 16 People who use the service commented, “I enjoy my food at the home”. Relatives commented “There have been issues with mum at meal times; these have been dealt with sensitively” “From what I see, the food is varied and of good quality”. Stanley Burn Care Centre DS0000063750.V363078.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The views of people who use the service, and their relatives are listened to and acted upon. People who use the service are protected from abuse, neglect and self-harm. EVIDENCE: The complaints procedure is available in the service users guide and a copy is available at the front entrance of the home. People who use the service and relatives spoken to understood how to make a complaint, and could identify the way this would be dealt with. People who use the service commented, “I always ask to speak to the manager or deputy manager”. Relatives commented “Excellent, prompt response” “The laundry is very poor at times and white articles are muddy grey in colour. I do complain and things improved - but it seems to be an ongoing problem” “The manager is very approachable and always tries to help. I can discuss anything with her and can also complain to her if necessary, and she responds immediately. I have a Stanley Burn Care Centre DS0000063750.V363078.R01.S.doc Version 5.2 Page 18 very good rapport with her which I feel is essential” “I have never had any need to complain about the care my husband is receiving”. Staff have undertaken the one day training on the Protection of Vulnerable Adults and there is further training planned. Staff were aware of the whistle blowing policy and felt able to raise concerns if necessary. The manager was aware of the need to protect all people who use the service. Stanley Burn Care Centre DS0000063750.V363078.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The facilities are designed to meet the needs of people who use the service. It is homely, generally well maintained and clean. EVIDENCE: The home is comfortable and attractively furnished. The bedrooms are attractive and homely and reflect their individual styles and tastes. The home has sufficient and suitably equipped bathrooms. A new specialised bath had been fitted enabling staff to provide a more comfortable bathing experience for people who use the service. Many of the carpets, furniture and furnishing had been replaced throughout all of the units and the general maintenance was good. Stanley Burn Care Centre DS0000063750.V363078.R01.S.doc Version 5.2 Page 20 The laundry and sluicing areas had been refurbished providing staff with better equipment and facilities to maintain the improved hygiene practices. The development of the outdoor/sensory garden area has provided additional areas and was being enjoyed by people who used the service. Relatives commented, “Cleaning and decoration are thoroughly done. For example, the new carpet, chairs and furnishings are appreciated” “The home is warm, comfortable”. Stanley Burn Care Centre DS0000063750.V363078.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are adequate numbers of appropriately skilled and experienced staff to care for the people who use the service. The recruitment processes in place protect people who use the service. EVIDENCE: Staffing rotas showed that there are now enough staff on duty to meet the necessary staffing levels. People who use the service commented, “The staff are very caring and understanding”. Relatives commented “Well-trained staff; most very experienced” “There is always the chance that a younger, inexperienced member of staff may have to deal with an unexpected situation, of course, the great majority of the staff are dedicated, experienced and brilliant” “Senior staff very good - their prompt action much appreciated, whether face-to-face or phone conversations to inform me” “Communications are good” “Dealing with individual residents with patience and compassion” “Pleasant atmosphere” “Caring and able staff” “The staff are always very friendly and will always listen to what I say and helpful when I ask any questions about my husbands welfare”. Stanley Burn Care Centre DS0000063750.V363078.R01.S.doc Version 5.2 Page 22 Health and social care professionals commented “Staff at the home seem to receive a lot of in-house training” “I would say staff are well balanced in a range of skills and abilities, the more experienced ones guiding the less” “Interacts well with clients and creates a very welcome, secure, friendly environment” “Trains care assistants in dementia care to provide competent care”. Recruitment procedures within the home are safe. Records confirm that appropriate checks are carried out for all staff. The home has an induction programme and the homes trainer is currently developing the training programme for all staff working in the home. Staff spoke knowledgably about the individual needs of people who use the service. Staff had undertaken refreshers in mandatory training. Nineteen staff are undertaking or had completed a National Vocational Qualification (NVQ) in Care level 2, or above. Catering staff have or are completing training in Basic and Intermediate Food Hygiene. All staff have undertaken Yesterday, Today and Tomorrow training which is aimed at working with people with dementias. The VIPS framework which places emphasis on a value based, individualised, service user perspective to provision of care, are further ways of enabling staff to support the person centred care approach. Staff meetings are used to provide additional in-house training. Stanley Burn Care Centre DS0000063750.V363078.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home is consistent and effective and offers leadership to the staff; this improves the life of the people living in the home and protects them from harm. EVIDENCE: The manager is an experienced care home manager who has worked at the home for a number of years. The manager has completed the dementia mapping course to provide additional direction for staff working with people with dementias. The leadership in the home both in the way the care is being delivered to the people who use the service and the overall organisation is Stanley Burn Care Centre DS0000063750.V363078.R01.S.doc Version 5.2 Page 24 good. This includes the organising of training and staffing, and ensuring that the home was being well maintained and equipped. Staff are confident in their work and are well supported. The staff, people who use the service and relatives were confident that their views were listened to and valued by the Manager. Relatives commented “The manager and the staff are always very friendly and helpful in every way” “The manager and her staff do their best to provide the level of care they believe their residents need and deserve” “The care home is managed very well”. Health and social care professionals commented, “I know that Ms Selby instils in her staff the importance of respecting the individual. I have had people there both on respite and in permanent beds. Their relatives hold her in high esteem and she is most attentive during difficult/crisis times which they appreciate” “Andrea and the staff have a good working relationship with the mental health team based in Hexham. They have no hesitation in either ringing us for advice, or discussing cases with individuals when they are visiting the home. Often they will problem solve themselves and use strategies and techniques which have helped in similar cases” “Its good to know they take on board and act on advice” “The home manager always takes on board any concerns raised by clients, relatives or professionals and responds appropriately/seeks advice or support” “Andrea Selby is a positive role model to all her staff and is a competent confident manager”. Accident and risks assessment are appropriately documented with good links established with the local health falls prevention programme. The Annual Quality Assurance Assessment was well completed and returned to Commission for Social Care Inspection. This document reflects the standard of the service being provided and the way the manager/provider plan to improve it further. The provider has good quality assurance systems in place including annual surveys, audits on areas such as menus, service user plans, staff recruitment and training, and health and safety, and is currently introducing a self assessment tool. The home has just achieved the Investors in Peoples Award. Twice yearly meetings are held for people who use the services and their relatives. Regular staff meetings are also held. The health and safety audit and maintenance of the home were satisfactory. Stanley Burn Care Centre DS0000063750.V363078.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 Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 3 Stanley Burn Care Centre DS0000063750.V363078.R01.S.doc Version 5.2 Page 26 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. 1 Standard OP7 Regulation 15 Requirement The Manager to ensure all service user plans are updated and involve the people who use the service and/or their supporters, where possible Timescale for action 01/11/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP12 Good Practice Recommendations To develop an individualised social opportunities plan for all of the people who use the service Stanley Burn Care Centre DS0000063750.V363078.R01.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 Stanley Burn Care Centre DS0000063750.V363078.R01.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. 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