Inspection on 24/11/05 for 19 Leicester Villas

This inspection was carried out on 24th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

19 Leicester Villas 26/04/07

19 Leicester Villas 20/04/06

19 Leicester Villas 26/05/05

19 Leicester Villas 26/01/05

19 Leicester Villas 31/08/04

19 Leicester Villas 03/03/03

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 19 Leicester Villas Hove East Sussex BN3 5SP Lead Inspector Jenny Blackwell Announced Inspection 24th November 2005 10:00 19 Leicester Villas DS0000031913.V249728.R01.S.doc Version 5.0 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 19 Leicester Villas DS0000031913.V249728.R01.S.doc Version 5.0 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. 19 Leicester Villas DS0000031913.V249728.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 19 Leicester Villas Address Hove East Sussex BN3 5SP 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) 01273 295840 Brighton & Hove City Council Ms Dee Holborn Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 19 Leicester Villas DS0000031913.V249728.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. That no more than five (5) service users are to be accommodated at any one time. 26th May 2005 Date of last inspection Brief Description of the Service: 19 Leicester Villas is a semi-detached property in a quiet, residential road in Hove. It is possible to walk to the shops, and public transport systems are within close proximity.The service is for up to five adults with learning disabilities. At the present time there are four service users who are supported 24-hours a day. 19 Leicester Villas DS0000031913.V249728.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. During this summary the people who live at the home will be referred to as people/person, and the people who work at the home as staff or by their job title. The people who live at the home, some of the staff team, the new deputy and temporary manager were present during the inspection. Some time was spent with three of the four people who live at the home. The temporary manager and deputy were spoken to individually and two staff were spoken to throughout the visit. A parent was spoken with during the inspection and two comment cards were received from relatives. The registered manager had not been working in the home since the middle of July 2005 and the Senior Care officer (deputy) had been redeployed. This left an acting S.C.O to manage the home for a period of time until the temporary manager was appointed via an agency to manager the home twelve weeks ago. The requirements that were made during the last inspection were checked to see if they had been met. Some had been met within the timescale, however one requirement was outstanding since August 2004, three requirements were outstanding from January 2005 and two requirements were outstanding from May 2005. The people who live at the home and the staff were helpful throughout the inspection and contributed to the report where possible. What the service does well: The staff have developed many more opportunities in the home for the people to be actively engaged in making choices and taking decisions. It was noted that the environment in the home was more focused on the participation of the individuals. Pictorial rota boards and menus were used to help the people understand which staff would be working and what meals would be prepared each day. The temporary manager stated that the staff had made progress with the people living at the home to access the kitchen and be involved in making drinks and preparing meals. The acting deputy and newly appointed deputy described the changes in the day activities for each person. Each person had a home day were they stayed at home away from their organised day services, to participate in 1:1 activities with the staff. The hours given over to the activities had been lengthened and 19 Leicester Villas DS0000031913.V249728.R01.S.doc Version 5.0 Page 6 were better organised, helping the people to have a better choice of activities and gain some consistency from the staff. The management intend to change the rota in the new year to give the staff better opportunity to carry out delegated tasks such as reviewing the peoples care plans, medication checks and health and safety checks. Both the comment cards from the relatives were positive about the staff and the support they provided for their relatives. One stated “ I cannot praise highly enough the care, kindness and feedback from staff on my brother.” What has improved since the last inspection? What they could do better: The ability for the registered persons to meet the requirements made under the Care Standards Act 2000 had been poor. It is with concern that the Commission notes the failure of the registered manager and Brighton and Hove City Council to adhere to the fire safety requirements for over a year. Several other requirements had not been met, one of which went back to August 2004. These included having appropriate community care assessments reviewed by a qualified person, having terms and conditions about living at the home for each person, the assessments of locks on people bedroom doors, refurbishing the kitchen and staff attending infection control training. The registered manager had significant absences from the home and the S.C.O (deputy) had been redeployed. Both the staff and relatives commented about the uncertainty and instability in the home not knowing what the management structure will be. The Commission intends to look at the lack of compliance with meeting the standards and the management of the home outside of the inspection process. 19 Leicester Villas DS0000031913.V249728.R01.S.doc Version 5.0 Page 7 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. 19 Leicester Villas DS0000031913.V249728.R01.S.doc Version 5.0 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 19 Leicester Villas DS0000031913.V249728.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-5 The manager and staff have access to policies and procedures covering new people moving to the home. The Statement of Purpose contained the information that allowed prospective people to make an informed choice of were to live. Placement assessments were not reviewed in all cases by the funding authorities. New people would have the opportunity to visit and try out the service. The people who live at the home do not have a contract of terms and conditions of residency. EVIDENCE: The temporary manager had made the adjustments to the Statement of Purpose required in the two previous inspections. The document now describes the function of the home and the accommodation to be provided. It was noted that some people had not had their placements at the home reviewed by Brighton and Hove Social Services on an annual basis. This had been required at the previous two inspections. The temporary manager had written to Brighton and Hove to invite them to their “in house” review of the peoples care. However the suitability of the placement needs to be assessed by the placing authority. 19 Leicester Villas DS0000031913.V249728.R01.S.doc Version 5.0 Page 10 A discussion took place between the manager and inspector about the expectation in the National Minimum Standards for the manager to ensure these assessment reviews take place. Although the manager could not guarantee the social workers from the placing authorities would conduct the reviews, he must provide evidence that he has requested the reviews take place annually. The requirement will continue and is now a matter of urgency. New people moving to the home are given information such as the Statement of Purpose and Service Users Guide that sets out information about the home. The staff receive training in supporting people with learning disabilities. The home has a policy about new admissions to the home which stipulates that new people admitted to the home would be given the opportunity to visit the service. The home did not have a specific contract with the people at the home. The manager stated that the Brighton and Hove City Council was working with the home to produce a clearer contract for the individuals. 19 Leicester Villas DS0000031913.V249728.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 The people are supported to make decision about their lives and are consulted on daily aspects of life. People were supported better to take risks and the staff had a better understanding of moving toward an independent lifestyle. The information about the people was stored appropriately and the staff understood the importance of maintaining confidentiality. EVIDENCE: The temporary manager stated the home arranges three monthly meetings for the people who live at the home. Generally the staff team have improved the level of participation in the home. The staff now include the people in preparation of the meals and consult them on their preferences through the day. The risk assessment process has also helped in enabling the people to participate around their home. One staff member spoken to said that the staff team have been focusing on improving communication with the people to help them make choices and be involved in the decision making process in the home. 19 Leicester Villas DS0000031913.V249728.R01.S.doc Version 5.0 Page 12 The personal information about the people is stored appropriately in the home. The manager ensured that records and files about the people were locked away and staff were seen to make sure the records were put back in a secure place after they had used them. 19 Leicester Villas DS0000031913.V249728.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,14 and 16. The staff had begun to enable the individuals to develop new skills. The people were engaged in a variety of leisure activities. The staff had begun to address some practices in the home that had previous not respected the people rights. EVIDENCE: As with the previous standards the staff had been given the opportunity through managerial support to improve the opportunities for personal development, appropriate leisure activities, and adhering to peoples rights. The acting deputy manager talked about the developments the staff had made with the peoples daily activities. She said that previously activities had not been as organised as they were now. The staff had structured the “home days” when individuals stay at home from their organised day centres. People now have a particular activity on their day. The staff are developing communication tools to ensure that the people know were they are going. The people engage in activities such as shopping, going to the cinema, yoga and swimming. The staff have also been addressing some practices at the home that encroached on the peoples rights. At the previous inspection the kitchen door was locked on occasions. The lock has now been removed and the temporary 19 Leicester Villas DS0000031913.V249728.R01.S.doc Version 5.0 Page 14 manager said that the staff team had become much better at supporting access to the kitchen. The staff had done risk assessment for each person to ensure that any risk in accessing the kitchen is reduced. Another member of staff reported that each person had been given a front door key to their home. One person in particular was enjoying using the key and the status that opening his own front door brings. The management and staff will need to continue this momentum to ensure the peoples participation in the home continues to improve. 19 Leicester Villas DS0000031913.V249728.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,20 and 21 The staff delivered personal care in a way that respected the individual’s privacy. People do not administer their own medication, as this was not appropriate. The staff followed the Brighton and Hove City Council policies and administered the medications appropriately. The illnesses of the people were handled with respect and the Brighton and Hove City Council had policies and procedures in the event of a person death. EVIDENCE: The staff ensure that the people are supported with their personal care in a respectful manner. The staff were seen to discreetly help people to the bathrooms. The individuals care plans described the preferred way in which the individuals liked to be supported. The people who live at the home were unable to self-administer medication, due to their abilities. A medication check was carried out with the manager present. The medications were stored correctly and securely. The new deputy manager was asked about the medication procedure and he was able to describe the way in which the medication was given to the people. 19 Leicester Villas DS0000031913.V249728.R01.S.doc Version 5.0 Page 16 The medication file was detailed. In each persons section a form was completed which described what each medication looked like, its function and side effects of the drug. This was a useful reference tool for the staff administering the medication. It was noted that one drug was referred to by both its brand name and drug name, which could lead to some confusion. It was recommended that the home refer to medicines as written on the medicines sheet from the pharmacist. The current group of people living at the home are fairly young and generally in good health. The care plans for each person highlighted particular health issues. The staff spoken to were knowledgeable about one persons condition and worked with him and his family to monitor any changes. 19 Leicester Villas DS0000031913.V249728.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 The people are generally protected from abuse by the Brighton and Hove City Councils policy, however further improvement was needed to ensure staff were trained and the management were compliant with requirements. EVIDENCE: At an inspection in August 2004 it was required that the manager review the locks on each persons bedroom to ensure that they were suitable for their needs. This has been looked at under the adult protection standard as the type of locks fitted to the doors could be misused by staff or other people living at the home. The current service user group would not be able to get themselves out of their bedrooms if the doors were locked from the outside. This requirement has not been met and there was no evidence to show that any work had been undertaken by the registered manager or Brighton and Hove City Council to begin the work. The lack of compliance was unacceptable and the requirement now needs to be met as a matter of urgency. The temporary manager stated he would work with the keyworkers to assess each person’s abilities to use the locks. Some staff had received training in adult protection although it was not clear that all staff had received the training. It was required that all members of the staff team receive training in protecting vulnerable adults. 19 Leicester Villas DS0000031913.V249728.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26,27,28,29 and 30. The environment was homely except for the kitchen and was generally safe, although fire safety was not addressed fully. The facilities provided in each person’s bedroom promoted their independence. The bathroom facilities were adequate and offered the people privacy. The shared space’s were small and did not complement the people’s private space. Specialist equipment was used by the staff which maximised people’s independence. The home was clean and hygienic. EVIDENCE: The staff team had made improvements to the environment in the home by putting up pictures and photos. A photo rota board had been put in the entrance hallway of the home so that the people could see which staff member was working. The lounge and dining area was small and the temporary manager stated the area could feel cramped when all the people were using the space. He said that it was worse during the winter months as the people used the garden a lot in better weather. The manager and inspector talked about the possibility of extending the home or adding a conservatory area. The Kitchen is in a poor state of repair. It had been required at the inspection in May 2005 for the kitchen to be refurbished, the flooring was poor as were 19 Leicester Villas DS0000031913.V249728.R01.S.doc Version 5.0 Page 19 the kitchen units. The kitchen needed to be designed around the needs of people so they could continue to have access to the kitchen and be involved in food preparation. The temporary manager produced some copies of letters to the Estates Officer of the South Downs Health NHS Trust. The Trust is responsible for the repairs and maintenance of the building and have been informed by Brighton and Hove City Council that the refurbishment needs to take place. The requirement is outstanding and now needs to be addressed as a matter of urgency. A requirement was made in January 2005 to ensure that all the staff received training in infection control as some staff spoken to in January had not had the training. Again this requirement is outstanding and had not been addressed by the registered manager. The current temporary manager had started to find out about which organisation would run a course. 19 Leicester Villas DS0000031913.V249728.R01.S.doc Version 5.0 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31-36 The roles and responsibilities of the management in the home were unclear. The staff members were competent in supporting the current group of people living at the home. The organisations policies and procedures for recruitment of new staff are followed by the home. The people are protected by a procedure that meets the requirements in the National Minimum Standards. Brighton and Hove City Council had a rolling training programme for staff, however information about the courses and qualifications of the staff team was not provided. Staff had not been supported fully in the absence of the registered manager. All the staff had received supervision from the temporary manager. EVIDENCE: The staff and relatives spoken to stated that the management roles and responsibilities had not been clear in the home for some time. With the support of the acting manager staff had a clearer understanding of their roles and responsibilities. More tasks had been delegated to the staff in the registered manager and deputy’s absence, this had been received well by the staff. Before the inspection the home is sent a pre inspection questionnaire to fill in with information about the service. This information is used during the 19 Leicester Villas DS0000031913.V249728.R01.S.doc Version 5.0 Page 21 inspection process to map the changes from one inspection to the other. The questionnaire was only partly filled in and did not provide the information about staff training and the N.V.Q qualifications of the staff. The staff spoken to said they looked at individual training in supervision and were able to attend courses. It was required that the manager supply an up to date list of qualifications of the staff and the courses they had attended. The staff recruitment records were seen during the inspection and were found to meet the standard required. Each staff member had references and Criminal Records check information in their file. The acting Senior Care Officer (S.C.O.) and the temporary manager had conducted regular supervision with the staff on 1:1 basis and appraisal documents were seen for one person and signed by both parties. This continuity was important as the staff spoken to had reported that it was not very stable at the home with the changes in the management. 19 Leicester Villas DS0000031913.V249728.R01.S.doc Version 5.0 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37-43 The people who live at the home had not benefited from consistent leadership or management of the home for most of the year. The home did not have a clear quality assurance tool although audit checks such as health and safety were carried out. The people’s rights were protected by the home’s policies and procedures, which were reviewed regularly. The record keeping protected the people’s interest. The health and safety of the people living and working at the home were not fully protected and fire safety in the home needs to be addressed as a matter of urgency. The organisation monitors the financial viability of the home. EVIDENCE: The registered manager had not been working in the home since the middle of July 2005 and the Senior Care officer (deputy) had been redeployed. This left an acting S.C.O to manage the home for a period of time until the temporary manager was appointed via an agency to manage the home twelve weeks ago. On a previous occasion in the beginning of 2005 another temporary manager had worked at the home to cover the absence of the manager and S.C.O. 19 Leicester Villas DS0000031913.V249728.R01.S.doc Version 5.0 Page 23 Both the staff and relative spoken to had said it had been a difficult and anxious time not knowing what would happen in the long run. Although it was difficult to ascertain if the people who lived at the home had been directly affected by the instability it was recognised that the constant change of personnel was disruptive. Some staff described morale as “low”. However it was stated by the staff that some positive changes had come about with the change of management and the staff were beginning to engage the people more around the home. The rota was going to be changed in the New Year to help staff have the time to do some delegated tasks such as medication and health and safety checks. It would also allow the people to have more opportunities outside of the home. A new S.C.O had been appointed to the home and he felt that that although he had been thrown in at the deep end, all the staff and the temporary manager had been really good at supporting him and he was looking forward to settling into the team. The acting S.C.O had felt that the staff had been brilliant at keeping the home on an even keel. The organisation undertakes different audits in the home to check for the quality of service the home provides. It was not clear if the organisation and home has a quality audit tool to meet the standard. It was required that the manager provides a quality audit tool to demonstrate the organisation and the home monitors the quality of service provide. A list of the home’s policies was forwarded as part of the pre inspection questionnaire. The policies are generally well reviewed and updated. The records held in the home are suitably stored and staff adhere to the record keeping policy. After an inspection in August 2004 serious concerns were raised with the registered manager and Brighton and Hove City Council about the practice at the home regarding fire safety. The Commission requested a visit to the home from a fire safety officer from East Sussex Fire and Rescue Service. The fire officer visited the home in November 2004 and made several recommendations to the home to improve its fire safety. A follow up visit by the Fire service was conducted in December 2004 and none of the recommendations had been dealt with. In January 2005 and inspection by the Commission found again that not all of the recommendations had been adhered to although some work had progressed, a further requirement was made. In May 2005 a fire risk assessment was organised by the manager to be conducted by the home’s fire safety contractors. Obtaining a fire risk assessment was one of the recommendations from the Fire safety officers visit. 19 Leicester Villas DS0000031913.V249728.R01.S.doc Version 5.0 Page 24 Recommendations to install devises to prevent the spread of fire were made. At an inspection in May 2005 a requirement was made for the home to implement the recommendations. This had not been met by this inspection. The temporary manager had been passed the information two months after he had started by the registered manager who had not taken steps to meet the requirement. The temporary manager had begun the process of implementing the recommendation although work to install devises to prevent the spread of smoke and fire had not been achieved. It is with concern that the Commission notes the failure of the registered manager and Brighton and Hove City Council to adhere to the fire safety requirements for over a year. This will be followed up outside of the inspection process. 19 Leicester Villas DS0000031913.V249728.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 1 3 3 2 Standard No 22 23 Score 2 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X 3 3 2 3 2 LIFESTYLES Standard No Score 11 3 12 X 13 X 14 3 15 X 16 2 17 Standard No 31 32 33 34 35 36 Score 1 2 3 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 19 Leicester Villas Score 3 X 3 3 Standard No 37 38 39 40 41 42 43 Score 1 1 2 3 3 1 3 DS0000031913.V249728.R01.S.doc Version 5.0 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 YA2 Regulation Requirement Timescale for action 24/11/05 2 YA5 3 YA23 4 YA23 5 YA24 6 YA30 14(1)(a)(b) It is required that the manager ensures a suitable qualified person reviews the service users placement at least annually. (from previous inspection 26/01/05) 5(1)(b) It is required that the manager ensures that terms and conditions of living at the home are in place for each service user. (from previous inspection 26/01/05) 23(2)(a) It is required that the manager assesses each service users lock to ensure it suits individual needs. (from previous inspection 31/08/04) 13(1)(6) It was required that all members of staff receive training in protecting vulnerable adults. 23(2)(a)(d) That the manager ensures the kitchen is refurbished to suit the needs of the people. (from previous inspection 26/05/05) 16(2)(j) That the manager ensures staff attend infection control training. (from previous inspection 26/01/05) DS0000031913.V249728.R01.S.doc 24/11/05 24/11/05 31/12/05 24/11/05 24/11/05 19 Leicester Villas Version 5.0 Page 27 7 YA32 18(1)(a) 8 YA39 24(1-3) It was required that the manager supply an up to date list of qualifications of the staff and the courses they had attended. It is required that the manager provides a quality audit tool to demonstrate that the organisation and home monitors the quality of service provide. That the manager implements the recommendations from the fire risk assessment.(From previous inspection 26/01/05) 31/12/05 28/02/06 9 YA42 23(4)(a-c) 24/11/05 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 YA20 Good Practice Recommendations It was recommended that the home refer to medicines as written on the medicines sheet from the pharmacist. 19 Leicester Villas DS0000031913.V249728.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 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 19 Leicester Villas DS0000031913.V249728.R01.S.doc Version 5.0 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!