Care Home: Tynevale Terrace

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What the care home does well Relatives and service users have a high degree of satisfaction with the home. Comments included, "The home is excellent. The food is good, we`re made to feel welcome. The home is well-run and organised. The care is very good. Staff excellent"; and, "Good, organised management. Staff are friendly and helpful. The care meets the needs of the service user." The manager would only admit someone if a full assessment of his or her needs has been carried out. This is so she can be sure that the home can meet all those needs. Detailed care plans are drawn up to show how staff are going to meet those needs. These care plans have proved very successful in settling some challenging behaviours and in improving the service users` quality of life. Health care needs, including the giving of any prescribed medications, are also fully met. Service users are treated with respect and dignity by the staff, and there is a calm and relaxed feel to the home. The home provides social and educational activities based on the assessed needs and wishes of the service users, and provides transport for trips out. Families are encouraged to keep in regular contact with the service users, and service users are helped to keep in contact with their local community. They have a good degree of choice as to how they spend their time. Service users help plan the weekly menus and enjoy a good diet, with plenty of choice, in very pleasant surroundings. The home has had no complaints in the past year. It takes a positive approach to any concerns or complaints, would take them very seriously, and look into them carefully. It also gives staff good quality training in how to protect service users from abuse or harm. The home is kept in a good physical and decorative condition, and is well maintained, as well as being kept in a clean and attractive condition. There are good levels of staff and more than half the staff are qualified. The home selects its staff carefully and gives them a very good level of training. The manager is very experienced in the management of care. She makes sure that staff are properly supervised and that the health and safety of both service users and staff are protected. There are systems in place to ask the opinions of those who use the service and their views are taken seriously and are acted upon. This is a very good home with the potential for excellence. What has improved since the last inspection? The home`s manager has been registered under the Care Standards Act. The home`s systems for fire safety have been significantly improved over the past year. The home has benefited from some re-decoration and new furnishings, and new flooring has been fitted. The manager and deputy manager are doing Equality and Diversity training. What the care home could do better: The `goals` section of the service users` care plans should be thought through and be made clearer. Better recording of the intake of fruit and vegetables should take place. CARE HOME ADULTS 18-65 Tynevale Terrace 9 Tynevale Terrace Gateshead Tyne and Wear NE8 2XY Lead Inspector Alan Baxter Key Unannounced Inspection 11th September 2008 09:30 Tynevale Terrace DS0000070145.V371807.R02.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Tynevale Terrace DS0000070145.V371807.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Tynevale Terrace DS0000070145.V371807.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tynevale Terrace Address 9 Tynevale Terrace Gateshead Tyne and Wear NE8 2XY 0191 4233081 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) Ashdown Care Homes Limited Mr Gary Craig Candlish Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Tynevale Terrace DS0000070145.V371807.R02.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 only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: 2. Learning Disability - Code LD, maximum number of places: 3 The maximum number of service users who can be accommodated is: 3 28th January 2008 Date of last inspection Brief Description of the Service: Tynevale Terrace provides personal care to three service users with learning disabilities. Staff provide care throughout the day and sleep-in staff are on site throughout the night. The service users participate in all activities within the home i.e. cleaning cooking and are escorted by care staff to appointments and to leisure facilities throughout the week. Tynevale terrace is a three storey property situated in a residential area in Bensham, approximately two miles from the central Gateshead. A small domestic type setting is provided in keeping with the local buildings and environment. The home has a small garden area to the front of the property and an enclosed yard to the rear. Car parking is available at the front of the house, which is shared with neighbouring properties. The home is situated within easy access to local facilities including doctor’s surgeries, dental practices, shops and leisure facilities. Bus and metro services are within walking distance of the home. Fees range from £633.00 to £649.00 Tynevale Terrace DS0000070145.V371807.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. How the inspection was carried out Before the visit: We looked at: • Information we have received since the last visit on 28/01/08. • 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 11/09/08. It lasted 5.5 hours. During the visit we: • • • • • • Talked with people who use the service, staff, and the manager. 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 what we found. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations – but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. Tynevale Terrace DS0000070145.V371807.R02.S.doc Version 5.2 Page 6 What the service does well: Relatives and service users have a high degree of satisfaction with the home. Comments included, “The home is excellent. The food is good, we’re made to feel welcome. The home is well-run and organised. The care is very good. Staff excellent”; and, “Good, organised management. Staff are friendly and helpful. The care meets the needs of the service user.” The manager would only admit someone if a full assessment of his or her needs has been carried out. This is so she can be sure that the home can meet all those needs. Detailed care plans are drawn up to show how staff are going to meet those needs. These care plans have proved very successful in settling some challenging behaviours and in improving the service users’ quality of life. Health care needs, including the giving of any prescribed medications, are also fully met. Service users are treated with respect and dignity by the staff, and there is a calm and relaxed feel to the home. The home provides social and educational activities based on the assessed needs and wishes of the service users, and provides transport for trips out. Families are encouraged to keep in regular contact with the service users, and service users are helped to keep in contact with their local community. They have a good degree of choice as to how they spend their time. Service users help plan the weekly menus and enjoy a good diet, with plenty of choice, in very pleasant surroundings. The home has had no complaints in the past year. It takes a positive approach to any concerns or complaints, would take them very seriously, and look into them carefully. It also gives staff good quality training in how to protect service users from abuse or harm. The home is kept in a good physical and decorative condition, and is well maintained, as well as being kept in a clean and attractive condition. There are good levels of staff and more than half the staff are qualified. The home selects its staff carefully and gives them a very good level of training. The manager is very experienced in the management of care. She makes sure that staff are properly supervised and that the health and safety of both Tynevale Terrace DS0000070145.V371807.R02.S.doc Version 5.2 Page 7 service users and staff are protected. There are systems in place to ask the opinions of those who use the service and their views are taken seriously and are acted upon. This is a very good home with the potential for excellence. 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. Tynevale Terrace DS0000070145.V371807.R02.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 Tynevale Terrace DS0000070145.V371807.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. People who use the service experience good quality in this area. The home makes sure that it can meet the needs of any person referred to it by carrying out its own detailed assessment, as well as getting an assessment from the person’s social worker. We have made this judgement using available evidence including a visit to this service. EVIDENCE: The home uses a good, detailed assessment format that includes lifestyle, strengths, physical, social and spiritual needs. There is also a ‘pen picture’ of each service user’s needs, which is highly personalised, and covers hobbies and interests, likes and dislikes etc. The manager expects a comprehensive assessment from any referring agency, and would not consider an approach without this. In a survey, all five staff said that they have the right support, experience and knowledge to meet the individual needs of the service users. Tynevale Terrace DS0000070145.V371807.R02.S.doc Version 5.2 Page 10 The home has a policy on equality and diversity, and both the manager and the deputy manager are currently doing a 12-week distance-learning course on equality and diversity. Tynevale Terrace DS0000070145.V371807.R02.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 and 9. People who use the service experience good quality in this area. Service users’ individual needs and choices are clearly set out in the care plans. These show that they are involved in making decisions about their lives, including the taking of reasonable risks. We have made this judgement using available evidence including a visit to this service. EVIDENCE: A care plan has been drawn up to meet each of the assessed needs of the service users. The care plans are very detailed and appear to be appropriate. It was recommended that the goal of each plan is made clearer. Care plans are evaluated every six months. Tynevale Terrace DS0000070145.V371807.R02.S.doc Version 5.2 Page 12 It was noted that, using these care plans, staff have been very successful in managing some very challenging behaviours by service users, so much so that the descriptions of the problems exhibited seem rather out of date, and do not reflect the much more positive behaviours currently being exhibited. The care plans are very person-centred and show that the service users have choice in all areas of their daily lives. In a survey, both service users said that they can always make decisions about what they do each day. One said that the staff always listen to them; one said they sometimes do. The home’s manager has had risk assessment training, and a new, more detailed risk assessment format has recently been introduced. Detailed risk assessments are also provided by the referring local authority. In-house risk assessments are being revised to show the current levels of risk from challenging behaviours, as well as the historical risk. There is an environmental risk file, which contains comprehensive and detailed risks on all aspects of the premises. This is kept up to date by annual reviews by the manager. Tynevale Terrace DS0000070145.V371807.R02.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. People who use the service experience good quality in this area. Service users are encouraged to be as independent as possible, and are supported to take part in a variety of leisure pursuits and interests, both in the home and in the local community. We have made this judgement using available evidence including a visit to this service. EVIDENCE: Each service user has an individual activity plan that includes education and occupation. For example, one service user attends college two days a week, and spends one day doing voluntary work in a local charity shop. On the other two week days, this service user spends one day doing personal shopping, going to the bank etc. and another day having one-to-one with staff for personal attention and ‘pampering’. Tynevale Terrace DS0000070145.V371807.R02.S.doc Version 5.2 Page 14 The service users make good use of local facilities such as cinemas, art galleries, parks, shops and bingo hall. They also enjoy going out for lunch. There are occasional trips out, with Beamish being a recent example. Each service user has an individual holiday, with staff in attendance. Both service users have regular family support, and staff provide transport where necessary. There are no unreasonable visiting restrictions. Friendships are encouraged and supported. Personal relationships would also be supported, subject to the Mental Capacity legislation. The home uses the ‘Emotional Freedom Techniques’ (EFT) approach to managing the challenging behaviours of one service user. This involves helping the person to concentrate on the positives in their life, and shows them how to manage their feelings when they are low. This has proved very successful, and the person appears to now get much more enjoyment from their daily living. Daily routines are flexible, and include the service users, one of whom likes to help to prepare the meals and do some household chores, and one, set the table for meals. Both bring their own washing down. Generally, service users are encouraged to increase their social skills, with some progress being achieved (e.g. service users now offer staff a cup of tea, if making tea for themselves). Service users have keys to their rooms, but choose not to use them. Staff always knock on bedroom doors and respect the service users’ privacy. They give them their mail, unopened. All activities are voluntary. Service users can use their rooms when they want. Staff were seen to talk to and interact naturally with service users. Meals are planned on a weekly basis, in conjunction with the service users. Staff try to strike a balance between personal choice and appropriate nutrition. Fruit is always available and staff encourage service users to eat fruit. However, food monitoring records, although kept, do not accurately record service users’ intake of fruit and vegetables. A recommendation is made in this report regarding this. One service user enjoys helping prepare meals and snacks. Tynevale Terrace DS0000070145.V371807.R02.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. People who use the service experience good quality in this area. Service users’ health care and personal care needs are fully assessed, and are properly met, through good training, safe systems and appropriate referrals to health professionals. We have made this judgement using available evidence including a visit to this service. EVIDENCE: Care records, surveys and observations showed that staff give sensitive and flexible personal support, maximising privacy and dignity, and helping service users maintain independence and control over their lives. Service users are included in the care planning process and their views are taken on board. Where necessary, guidance and support is given regarding personal hygiene. Daily routines are flexible. Tynevale Terrace DS0000070145.V371807.R02.S.doc Version 5.2 Page 16 Health care needs have been properly assessed and described. There was evidence of regular check ups with the usual range of community-based health professionals, and of appropriate referrals to specialists. Neither of the current service users self-medicate. Both have signed consent to medication forms. The Medication Administration Records (MAR) is pre-printed by the supplying Pharmacy. No unexplained gaps were found. The manager checks the MAR weekly, and also does a weekly stock audit. Medication training is given as part of induction. Both the manager and deputy manager have completed the N.C.F.E. level 2 course in the safe handling of medications; all the other staff are currently doing this course. Tynevale Terrace DS0000070145.V371807.R02.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use the service experience good quality in this area. Clear policies are in place for responding positively to any concerns or complaints, and service users are protected from abuse by appropriate systems and good staff training. We have made this judgement using available evidence including a visit to this service. EVIDENCE: A monthly meeting is held with the service users and, as part of this, they are asked if they have any concerns or complaints. The home uses a pictorial complaints form, to assist service users in making a complaint, should they wish to do so. In practice, there have been no complaints received in the past twelve months. Both service users said that they knew who to speak to if they are not happy, and both said they knew how to make a complaint. Similarly, all five staff that returned surveys said that knew what to do if anyone expressed concerns about the home. After consideration, the manager and deputy manager were able to describe the correct process for reporting allegations. No such allegations have been received by the home. Tynevale Terrace DS0000070145.V371807.R02.S.doc Version 5.2 Page 18 In surveys, both service users said that the staff always treat them well. All staff have either received, or have been booked to receive, ‘Safeguarding’ training (also known as Protection of Vulnerable Adults training). The manager has had more in-depth ‘safeguarding’ training. The manager is a qualified trainer in ‘Non-Abusive Psychological and Physical Intervention’ techniques. This gives staff the skills to divert a service user from potentially harmful behaviours, and to refocus their attention on more positive things. Evidence of its effectiveness is in the lack of challenging behaviour exhibited by service users in the past couple of years. Tynevale Terrace DS0000070145.V371807.R02.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 and 30. People who use the service experience good quality in this area. The service users enjoy a clean, hygienic, well-maintained and well-decorated environment that has been made significantly safer over the past year. We have made this judgement using available evidence including a visit to this service. EVIDENCE: In the past year, a new fire protection system that meets the requirements of the Fire Rescue service has been installed. New fire resistant doors have been fitted. Emergency lighting has been fitted throughout the home, linked in to the newly installed fire protection systems. The kitchen has been fitted with a heat detector and all rooms are fitted with smoke detectors. In order to ensure that staff is aware of the procedures to follow in the event of a fire, a new night time fire evacuation procedure has been implemented. Tynevale Terrace DS0000070145.V371807.R02.S.doc Version 5.2 Page 20 New PVC double glazed windows have been fitted to the rear of the building and external decoration has been carried out to the front of the home. Radiator guards are being fitted in one service user’s bedroom following a recent re-assessment of risk. 30] Hygiene and Control of Infection: A tour of the premises confirmed that the home is well maintained, clean and hygienic. Tynevale Terrace DS0000070145.V371807.R02.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 quality in this area. Service users are well protected by the good staffing levels, excellent commitment to staff training, and the care taken in recruiting new staff. We have made this judgement using available evidence including a visit to this service. EVIDENCE: Four of the five staff who returned surveys said that there are always enough staff to meet the needs of the service users; one said there usually is. The manager is currently updating the service’s job application form and criminal record declaration form to reflect best practice. Staff files examined were easy to follow and well organised. All contained application forms, an interview record and references. Two references are always sought, one from the last employer. Criminal Record Bureau clearance and Protection of Vulnerable Adults (POVA) first checks are also obtained for all staff. Tynevale Terrace DS0000070145.V371807.R02.S.doc Version 5.2 Page 22 In a survey, staff said that their recruitment had been thorough and fair. The induction process includes the first day orientation, followed by a very detailed, highly appropriate and focussed induction over the first three months of employment. All five staff who returned surveys said that their induction training covered all they needed to know. Staff mandatory training needs were seen to be up to date, with refresher/update training booked, where required. Client specific training includes ‘Non-Abusive Psychological and Physical Intervention’ techniques, ‘Emotional Freedom Techniques’, and Epilepsy training. All five staff who returned surveys said that they are given training that is relevant, that helps them understand and meet the needs of service users, and that keeps them up to date with new ways of working. Two carers hold National Vocational Qualification (NVQ) level 2 in care, and another three are working towards this. One carer holds NVQ level 3. Records showed that staff are given supervision at the required rate of six times per year. Appropriate minutes are kept. Tynevale Terrace DS0000070145.V371807.R02.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 and 42. People who use the service experience good quality in this area. The home is well managed, and is operated in the best interests of its service users. We have made this judgement using available evidence including a visit to this service. EVIDENCE: It was a requirement of the last inspection report that the manager must submit an application to the commission to be the registered manager. This has been carried out. The manager, who holds NVQ level 4 in care and the Registered Manager Award, is now registered for this service. Her job Tynevale Terrace DS0000070145.V371807.R02.S.doc Version 5.2 Page 24 description is appropriate. Both she and her deputy manager are doing a level 3 Equality and Diversity training course. The home’s annual survey of service users and relatives’ views is due to be sent out in October. Last years’ survey results were very positive. Comments included, “The home is excellent. The food is good, we’re made to feel welcome. The home is well run and organised. The care is very good. Staff excellent” (parent); “ Home seems well-run. Staff are friendly. The care is good. Overall; very good” (relative); and, “Care appears very good. Staff are pleasant and co-operative. Very good home” (social worker). The various elements that contribute to the home’s annual development plan are currently being drawn together into one document. There was evidence of ongoing quality audits of appliances, medications, accidents, fire logbook, etc. There is a monthly health and safety audit. Maintenance and repairs records are kept. All the necessary checks and tests of fire safety systems and equipment are carried out at the appropriate intervals. There are regular fire drills and fire instructions. As noted under standard 24, ‘Environment’, above, there have been considerable improvements in the fire safety systems in the home over the past year. Health and safety training has been arranged for staff for October. There have been no accidents in the past year. Tynevale Terrace DS0000070145.V371807.R02.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 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 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 3 X X 3 X 3 3 3 x Tynevale Terrace DS0000070145.V371807.R02.S.doc Version 5.2 Page 26 No. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 YA17 Good Practice Recommendations Tynevale Terrace DS0000070145.V371807.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Tynevale Terrace DS0000070145.V371807.R02.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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