Care Home: Three Sisters

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What the care home does well People who use the service are given good information about what is provided. So that they know what help they will be given. People who would like to move into the home are well assessed so that they and the staff team can be sure that their needs will be met. People are encouraged to make their own decisions everyday with some support from staff. The have a good quality of life with many choices and opportunities for positive experiences and chances to lead a more fulfilling life. People are involved in deciding what care they need and a plan is then drawn up. This gives everyone a say in planning services they will receive. The staff are safely recruited and well supported in understanding how to care for specialist health needs and to care in a safe way. The staff showed a good understanding and knowledge of the people they care for. They look after them in a friendly and supportive way. People are given the chance to have their say about how the home is run in regular meetings and reviews. This is important to make sure that their opinions are included in any changes to the service. What has improved since the last inspection? People at the home now have a contract, which is up to date and informs them of their rights whilst living at the home. The night staff have all been trained to give medication to make sure that prescribed medication is available day and night. This is to make sure the home can fully meet the health needs of all people living at the home. The care plans and risk assessments have got better making sure that any restriction of freedom or choice is clearly agreed and recorded in the individual`s care plan. What the care home could do better: The manager and staff have worked hard in the last year to provide a good quality of care for people living at the home and they must be commended for this. Unfortunately the living conditions have deteriorated significantly and the communal areas of the home are in urgent need of repair, redecoration, and refurbishment. People living at the home do not have a telephone they can use independently without using the home phone. Whilst a payphone has been fitted it does not work. CARE HOME ADULTS 18-65 Three Sisters Brow Top Road Haworth West Yorkshire BD22 9PH Lead Inspector Linda Trenouth Key Unannounced Inspection 18th September 2007 09:15 Three Sisters DS0000063426.V342613.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 Three Sisters DS0000063426.V342613.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. Three Sisters DS0000063426.V342613.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Three Sisters Address Brow Top Road Haworth West Yorkshire BD22 9PH 01535 643728 01535 645892 three-sisters@tiscali.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Voyage Ltd Mrs Clare Butcher Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Three Sisters DS0000063426.V342613.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th August 2006 Brief Description of the Service: The Three Sisters is a care home for 10 younger adults with a learning disability who may also have a challenging behaviour. The building was converted from bed and breakfast provision and is of a high standard. All accommodation is provided in single en-suite bedrooms. Communal spaces include kitchen, large dining room and lounges. The home is located in 18 acres of land and includes an on-site farm. The home is in easy reach of Howarth and the local facilities. Keighley is approximately 3 miles from the home and there is access to local transport. The homes people carrier is also able to transport individuals to local towns and cities to access a wider range of facilities. The fee range is from £1229 to £2030. There are extras charged for which include transport, outings, clothing, personal toiletries, and cigarettes. Three Sisters DS0000063426.V342613.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. I visited the home unannounced and stayed for approximately 6 hours. The inspection also included gathering information and proof before and after the visit to decide the overall judgement. The deputy manager was available throughout the inspection. During the visit I looked at the records, watched staff working, and talked to people who live at the home. I also looked around the building. The main purpose of this inspection was to make sure that the home continues to provide a good standard of care. I sent comment cards to people living at the home, relatives, visitors, and spoke to social and health care professionals, to give them the opportunity to comment on the service. Eight comments cards were received from people who live at the home. The manager completed a self-assessment form called an AQAA, which is information sent to the CSCI every year by the care provider. This helped prepare for this inspection. I talked to the deputy manager the next day about the outcomes of the visit. Requirements made during this visit can be found at the end of the report. What the service does well: People who use the service are given good information about what is provided. So that they know what help they will be given. People who would like to move into the home are well assessed so that they and the staff team can be sure that their needs will be met. People are encouraged to make their own decisions everyday with some support from staff. The have a good quality of life with many choices and opportunities for positive experiences and chances to lead a more fulfilling life. People are involved in deciding what care they need and a plan is then drawn up. This gives everyone a say in planning services they will receive. The staff are safely recruited and well supported in understanding how to care for specialist health needs and to care in a safe way. The staff showed a good understanding and knowledge of the people they care for. They look after them in a friendly and supportive way. Three Sisters DS0000063426.V342613.R01.S.doc Version 5.2 Page 6 People are given the chance to have their say about how the home is run in regular meetings and reviews. This is important to make sure that their opinions are included in any changes to the service. 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. Three Sisters DS0000063426.V342613.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Three Sisters DS0000063426.V342613.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5. People who use the service experience good outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People’s needs are assessed and they are given information and have the opportunity to visit the home before they move in to make sure the service is right for them. EVIDENCE: The “service user guide” which is a book which tells people how the service works, is written in a clear and understandable way. I spoke to one person who told me that he has been given a service user guide and was helped to understand his contract. He had also signed his own contract. This is important to make sure everyone is aware of their rights whilst living at the home. People said they had several opportunities to visit and stay at the home before deciding to move in. The comment card returned also confirmed this; “I watched a DVD of Three Sisters and mum and dad looked round to see if I would like it” “I came to visit before moving in” Another person said that he had visited the home with his social worker prior to moving in and felt he was given enough time to decide if the home was right Three Sisters DS0000063426.V342613.R01.S.doc Version 5.2 Page 9 for him. This is important in making sure that people have all the information they need before making the decision to live at the home. People’s needs were assessed prior to coming into the home by the care management teams in their local area, this is to make sure that the care home meet all the needs of the individual. The organisation also complete their own assessment before a place is formally offered. Three Sisters DS0000063426.V342613.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. People who use the service experience good outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People are able to make their own choices about how they live their lives both in the home and the wider community. EVIDENCE: People I spoke to felt that they made decisions about what they wanted to do each day. They felt that they made choices in their daily lives and that where necessary staff supported them in their decision-making. Assessments and care plans are completed and regularly reviewed. This makes sure that the changing needs of people living at the home are continually met. Staff told me that they were aware of the individuals that needed more support to make decisions. The staff I saw are skilled at communication, patience and supporting people making sure there is a good range of options and people can make decisions at their own pace. Three Sisters DS0000063426.V342613.R01.S.doc Version 5.2 Page 11 Staff explained how they include people in understanding their care plans and made sure that they are involved in any change of decisions within them. The plans are good and identify what action staff need to take to support someone in their life at the home. One person said that they were involved in their care plan. All people have access to their information; I spoke to one person who told me he regularly looked at his notes and care plan. Access to their information is important in making sure people feel involved with their care and staff are open and honest with them. People said they know who their key worker is but they also felt that they could talk to other staff if they needed to. This is important to make sure that the people feel supported by the whole of the staff team. Three Sisters DS0000063426.V342613.R01.S.doc Version 5.2 Page 12 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 and 17. People who use the service experience excellent outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The people who live at the home have excellent opportunities to experience and enjoy fulfilling lives both within and outside the home. EVIDENCE: There are a great deal of varied and creative activities happening throughout the week, which are right for the needs and abilities of the people living at the home. One individual told me about how he really enjoyed the trips out that he and the staff went on. He had been cycling and camping with the staff and looked forward to doing this again.. Three Sisters DS0000063426.V342613.R01.S.doc Version 5.2 Page 13 A plan of all people’s activities are kept but staff are encouraged to be spontaneous with ideas and respond to the wishes of the individual. The survey cards returned confirmed that people felt there are lots of activities on offer. Individuals are supported to practice their faith and one individual attends his local church when he wishes. People are supported to develop and maintain relationships with families and friends. They are assisted to visit their families and can meet their visitors in private. I joined people for lunch and the mealtime is not rushed or hurried. People are clearly relaxed with the staff and the atmosphere is calm and comfortable. Everyone joins in the mealtime including the staff. People living at the home are involved with planning menus and have a good choice of food and drinks at mealtimes. This ensures that they have a varied diet of their choosing and can enjoy their meals. The facilities based at the home linked into the farm and some of the people participated in the activities based there. The farm activities manager said that people living at the home are closely involved with the looking after and care of the livestock. This includes sheep, highland cattle, goats, and hens. One person told me that he collected the eggs and did some “mucking out.” People were also involved with gardening work supporting other homes in the Milbury group that are in the area. The staff felt that this was a positive experience for people they became involved and responsible for the animals. One individual told me he liked to be involved with the gardening side as he got paid. He liked to earn extra money. One person told me how he had undertaken a college course on computers last year and was now progressing to the next stage. He enjoyed the college and looked forward to going. I saw staff supporting people to pursue their college options but also encouraging people to organise their own placements were possible. Other people were involved with activites such as bowling, cinema, visits to local pubs and shopping in the town centre. Activities enjoyed include cricket and football. One individual had just returned from the Edinburgh fringe where he took part in the festival with a drama group. Others have enjoyed day trips to local towns and further afield to places like Bridlington and Blackpool. Three Sisters DS0000063426.V342613.R01.S.doc Version 5.2 Page 14 Some individuals also attend supporting day centres such as the Cathedral centre in Bradford and specialised Autism care. The company pay for one 5 day holiday per year for all the everyone in the home. The staff said that they help in the choice of the destination and type of holidays for each individual. A healthy diet is encouraged at the home. The residents house meetings focus on food and different choices for the menu. Individuals can make drinks for themselves during the day and are encouraged to help with the shopping and with the preparation of food. The comment cards confirm that people felt that there are good activities at the home. There is a good creative skill mix in the staff at the home and in the last year art and music groups have been formed. Staff said that people have enjoyed experimenting with differing musical instruments and sounds. Other staff have organised more physical activities such as recreational walking, cycling and more adventurous ideas such as abseiling. There are many photographs displayed on the walls of the lounge and in photobooks to show the activities people have taken part in. Good staffing levels and a good skill mix brings to the home innovative and creative opportunties for people to live a more fulfilling life. Three Sisters DS0000063426.V342613.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, and 20. People who use the service experience good outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The staff make sure that the people who live at the home stay fit and healthy. EVIDENCE: The care plans indicated that people had regular health checks with their GP, Dentists, Chiropodists and where required Psychiatric and Behaviourist Services. People use the local G.P, Dentist, and Chiropodist for their Health needs, this is important to make sure where possible people are using the local community. I spoke to staff that told me that they accompany people on their GP visits but do encourage individuals to take responsibility for their own health. Staff spoken to told me how they kept up with good practice and are aware of their responsibilities to make sure the people had regular health checks Medication had been reviewed since the last inspection and night staff have all been trained in the administration of medication to make sure that their health needs can be met throughout the day and night. Three Sisters DS0000063426.V342613.R01.S.doc Version 5.2 Page 16 Staff check and record the medicines they receive from the pharmacist to make sure it is correct. The controlled medication is recorded and second checked by two staff and the pharmacist receipts any medicines that are returned. Three Sisters DS0000063426.V342613.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 and 23. People who use the service experience good outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The management of people who have challenging behaviour has improved; staff are now trained and feel more confident to support individuals. Concerns and allegations are responded to promptly and in accordance with the local adult protection procedures, which make sure that people are listened to and are kept safe. EVIDENCE: The manager has made sure that special assessments have been undertaken for all people who exhibit differing levels of challenging behaviour. The staff have now all had training in the management of different behaviours to make sure that everyone is safe and that staff feel confident to manage situations when they arise. Staff said they felt more confident now about managing difficult behaviours and understood what is expected of them. When any incident occurs or restraint is used this is well recorded. There is a clear complaints procedure within service user guide. This procedure is in a simple format and reassures complainants that their complaint will be investigated. There has been some concerns made directly to the home, which have been investigated thoroughly and responded to promptly. There have been no concerns made to the CSCI (Commission for Social Care Inspection). Three Sisters DS0000063426.V342613.R01.S.doc Version 5.2 Page 18 People told me that if they had any concerns they would talk to the staff their key worker, one person said that he would talk to the manager or deputy manager. The comment cards confirmed that people knew who to talk to if they were unhappy, comments included, “If I am unhappy I would talk to my key worker” Staff have a good understanding of the protection of vulnerable adults and have received in-house training on adult protection in their induction. This means that staff have a better understanding and are aware of their responsibilities to protect people living at the home. The management and staff at the home have good relationships with the adult protection department and local police. This shows that the organisation is open to any concerns that are raised and wants to make sure that people are safe. Three Sisters DS0000063426.V342613.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, and 30. People who use the service experience adequate outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People’s own rooms are comfortable and homely, but maintenance of the communal areas is not kept up to. EVIDENCE: I toured the home and saw that the general level of care of the property was inadequate. The main lounge to the home was in need of refurbishment and redecoration as were corridors and the hallway of the home. Walls were stained and paper ripped. Some furniture was torn and should be replaced. The carpets seen throughout the building are deeply stained and may not be right for the needs of the home. They should be deep cleaned or replaced. Plasterwork that is damaged and has not been repaired and overall these areas looked very poor. The home does have a lot of wear and tear but the management must make sure that the environment is properly maintained to Three Sisters DS0000063426.V342613.R01.S.doc Version 5.2 Page 20 make sure that people live in good environment and can feel more positive about their home. Staff agreed that the home looked in a poor state and said that they do pass on maintenance problems but these areas have not been addressed. One individual showed me their bedroom, this is a pleasant room with no maintenance concerns and the person said that they had bought things for the room and that they arranged things, as they liked. They also have a lock to the door and feel able to keep their possessions safe. All people have their own bathrooms in their room, there is one communal toilet, but this did not have a working lock. Therefore people living at the home or visitors did not have their privacy protected. At the last inspection the home was required to fit an independent telephone for people living at the home to use. A payphone has been fitted but staff told me the phone does not work. A working telephone must be provided. The grounds around the home and the access people have around the lake and farmland is very good. One person I spoke to said he enjoyed the outdoors and didn’t like being stuck inside. He enjoyed being able to walk around and look at the lake and the farm animals. Three Sisters DS0000063426.V342613.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, 33, 34, 35 and 36 People who use the service experience good outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People at the home benefit from a well-supported and trained staff team who are competent and understand their needs and work in the best interests of each individual. EVIDENCE: The people at the home benefit from a stable staff group, which has provided consistent support and good understanding of the person’s support and needs. I looked at new recruitment since the last inspection and this has been done safely with new staff undergoing induction training. I spoke to staff that confirmed they had been recruited safely and finished their completed induction training. New staff work along side existing staff to make sure they are able to do their work competently and safely. The home has 23 staff, nine of these staff have achieved NVQ (National Vocational Qualification) level 2, and others are to enrol on N.V.Q courses, the home is aiming to achieve 50 of the work force being NVQ trained. A training needs assessment is carried out for the staff team and all staff Three Sisters DS0000063426.V342613.R01.S.doc Version 5.2 Page 22 within the home have individual training files and a training matrix is in place, this shows what training has been achieved and when updates are due, helping the manager make sure that all training is well managed. Staffing levels are good at the home making sure that people receive a better quality of care at all times. I spoke to staff who told me that they had supervision and team meetings regularly. Three Sisters DS0000063426.V342613.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, 38, 39 and 42. People who use the service experience good outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People benefit from a well managed service that is committed to ensuring an open and positive atmosphere is prevalent. EVIDENCE: The consistency of management has improved in the last two years and the home is now well run and people have a good quality of life. Staff said that they have more confidence in the way they work and what is expected of them. The manager has created an open and accountable service, which is accepting of criticism and works hard to resolve any concerns and complaints that are raised. The home works with good health and safety policies and procedures and all staff receive training in safe working practices, moving and handling, first aid, Three Sisters DS0000063426.V342613.R01.S.doc Version 5.2 Page 24 fire safety. The health and safety records are up to date. This included, PAT testing (Portable Appliance Testing), electrical safety, gas and water temperatures. The company has taken out the right insurance to make sure everyone is adequately protected. The home routinely consults with everyone, house meetings and staff meetings are held and families are annually surveyed. This makes sure that everyone has a say in how the home is run. Some of the staff have finished their basic first aid training and all staff have health and safety training as part of their induction training at the home. The manager makes sure that this training is updated when necessary. The manager makes sure that good relationships are built and maintained with both social and health care professionals. The community team for learning disabilities said that the manager was very professional in all aspects of her work and the home was well managed, coping with people with challenging needs. Comments were made such as, “Three sisters are professional in everything that they do” “The manager is excellent and responsive and keeps us informed of everything” The area manager has visited the home regularly on behalf of the registered provider to make sure that the home is running well and to support the manager. During his visits he monitors health and safety but also talks to staff and individuals to ask them their views about the home. The manager has now sought the views of people by sending out qualitative questionnaires to relatives, advocates, staff and stakeholders involved in the service. The findings of this survey must be made into a report and shared with all parties and a copy sent to the CSCI. Three Sisters DS0000063426.V342613.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 3 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 1 25 3 26 x 27 x 28 x 29 x 30 x STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 4 13 4 14 4 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 4 3 x x 3 x Three Sisters DS0000063426.V342613.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. 1 Standard YA24 Regulation 16.2 Requirement Timescale for action 01/12/07 2 YA24 13 A suitable telephone must be provided for people who live at the home and fitted in an area, which ensures privacy. Previous timescale 16/10/06 not met. The communal areas identified in 01/01/08 the report – main lounge, corridors and hallway - must be cleaned, redecorated, refurbished and maintained so that people live in comfortable and pleasant surroundings. 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 YA35 YA39 Good Practice Recommendations 50 of care staff should achieve NVQ level2 or equivalent. The findings of the quality survey should now be made into a report and shared with all parties and a copy sent to the CSCI Three Sisters DS0000063426.V342613.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Three Sisters DS0000063426.V342613.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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