Inspection on 12/09/07 for 42-44 Lansdowne Road

This inspection was carried out on 12th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

42-44 Lansdowne Road 22/11/06

42-44 Lansdowne Road 28/12/05

42-44 Lansdowne Road 19/05/05

42-44 Lansdowne Road 06/12/04

42-44 Lansdowne Road 07/06/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 42-44 Lansdowne Road Leicester Leicestershire LE2 8AQ Lead Inspector Ms Rajshree Mistry Key Unannounced Inspection 12 September 2007 10:00a th 42-44 Lansdowne Road DS0000006439.V347029.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 42-44 Lansdowne Road DS0000006439.V347029.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. 42-44 Lansdowne Road DS0000006439.V347029.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 42-44 Lansdowne Road Address Leicester Leicestershire LE2 8AQ 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) 0116 283 2780 0116 283 3243 Lansdowne Road Limited Ms Lesley Wakefield Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 42-44 Lansdowne Road DS0000006439.V347029.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No additional conditions of registration. Date of last inspection 22nd November 2006 Brief Description of the Service: 42 - 44 Lansdowne Road is registered to provide care for eight adults with learning disabilities. 42-44 Lansdowne Road is part of the Craegmoor Ltd group of homes. 42-44 Lansdowne Road is of one semi-detached property and one detached property situated next door to each other. The home is situated close to Aylestone Road on the bus route to the city centre. The home is in a residential area, close to local shops, parks and a leisure centre. People who live in the home are able to live independently and supported to develop living skills, access community activities, education and social events. People have their own bedroom and share the kitchens and bathrooms facilities. The inspection reports are available at the home or upon request. The fees start at £317 and increase dependent on the assessment of needs and additional support required by the individual service user. This information was received at the site visit and people interested in using the services should contact the home. 42-44 Lansdowne Road DS0000006439.V347029.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection process consisted of reviewing the last inspection report, reviewing and gathering of evidence from the Annual Quality Assurance Assessment (AQAA) – the Provider’s self assessment, and reviewing the service history of significant events since the last inspection. Surveys were sent from the Commission for Social Care Inspection to the service users, their relatives, health care professionals, who were identified in the AQAA and staff. The unannounced site visit commenced on the 12th September 2007 and lasted 1 day. The focus of the inspection is based upon the outcomes for the service users. The method of inspection was ‘case tracking’. This involved identifying service users with varying levels of care needs and looking at how these are being met by the staff at 42-44 Lansdowne Road. Two service users were selected, their care files read and discussion was held with one service user, as the other service user preferred not to speak with the Inspector. Another service user requested to speak with the Inspector after the site visit but was not contactable by telephone. Observations were made of other service users and their visitors who were not part of the ‘case tracking’ process. Discussions were held with the staff on duty with various responsibilities within the home and reading the records in relation to the running of the home, staff training records and the minutes of team meetings. The CSCI sent out seven surveys to service users and their relatives, of which 57 were returned from service users and 14 returned from relatives. All the responses were positive about the care and support provided at 42-44 Lansdowne Road. Three surveys sent out to Health Care Professionals such General Practitioners, District Nurse Team and Care Management Team but non were returned. The CSCI sent out ten surveys to staff at the home of which 10 were returned. Comments incorporated within Service Users Surveys and direct comments included: “I wanted to come to Lansdowne Road” “I do tell . . . . . . if there’s something wrong” The kitchen and bathroom are crap, in need of improvement” “Get windows sorted out and door frames” Comments received in the staff surveys: 42-44 Lansdowne Road DS0000006439.V347029.R01.S.doc Version 5.2 Page 6 “All information comes straight to the home” “Our manager is very supportive. We have appraisals every 2 months to discuss our progress/aims” “We have a communication book for support workers and communication book for the senior team” “We need bigger budgets for food/activities” What the service does well: What has improved since the last inspection? 42-44 Lansdowne Road DS0000006439.V347029.R01.S.doc Version 5.2 Page 7 The new assessment tool has been developed as part of the pre-assessment process for people considering 42-44 Lansdowne Road as their home. Improvements have been made to the care planning process, which now focuses on the individual service user, looking at their whole lifestyle, care needs, interests and goals. The plans involve the service users and people that are important to them to promote and maintain their preferred lifestyle. Improvements made with the installation of double-glazed to some windows; replacement of fire extinguishers and other works such as the new wet flooring is on order. The requirements and recommendation made at the last inspection have been addressed and evidenced during the site visit. Information received from the Registered Manager before the site visit stated staff awareness to reporting and dealing with concerns/complaints has been improved, and service users are supported to make a complaint or express a concern. The internal ‘Clinical Governance Audit’ process is being introduced to manage the quality and delivery of the service. 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. 42-44 Lansdowne Road DS0000006439.V347029.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 42-44 Lansdowne Road DS0000006439.V347029.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users have information about the home; involved in the assessment process to make sure the home is able to meet their needs. EVIDENCE: The information about the home is provided to service users before and at the first visit. The information sets out the type of care and support people would receive living at the home, the facilities, the staff skills and management arrangements. The ‘statement of purpose’ sets out the aims and objectives of the home. This information is detailed and is being revised and updated into formats suitable to the service users. Service user said they visited the home and had information about the home from the social worker. Service users care files viewed, had a record of the assessment of care needs carried by the Care Management Team at the time when the service user moved in and had information from other professionals involved. Service user said they were involved in the assessment process, identifying the care needs and goals. The service users’ survey responses confirmed people received information about the home and were involved in the assessment. 42-44 Lansdowne Road DS0000006439.V347029.R01.S.doc Version 5.2 Page 10 The Deputy Manager said the home carry out their own assessment of the service user’s needs to make sure they can meet those needs. The assessment format used has been updated, as stated in the information received from the Registered Manager before the site visit. The Registered Manager and senior staff are being trained to use the new assessment form. Information received from the Registered Manager before the site visit stated all service users have a contract with the terms and conditions of their stay and found in the care files. Comment received from the service user’s survey: “I wanted to come to Lansdowne Road” 42-44 Lansdowne Road DS0000006439.V347029.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are supported to continue and develop their lifestyle; making their own decisions and contributes to views in running of the home. EVIDENCE: Service user said they have been involved in developing their plan of care, respecting their choice of lifestyle, daily routines whilst promoting their independence. Care plans read for two service users were focused on the individual, detailed the care and the support they needed; arrangement for their medication, the important people in their lives; activities and their goals they want to achieve. The information received from the Registered Manager before the site visit stated that care plans are developed from the assessment. Staff said they have been involved in updating the care plans to be person centred, looking at the person and their life. Staff showed good awareness of service user’s needs 42-44 Lansdowne Road DS0000006439.V347029.R01.S.doc Version 5.2 Page 12 and how to encourage and support them to make decisions about their daily life. Care plans showed that the involvement of service user’s and what support they needed if they were anxious or at risk. Service users were seen making daily choices in what they did, for example doing their laundry, shopping or going out. The majority of the service users were out for the day, either at college, visiting friends socially or joining in community activities locally. Staff said service users would let them know where they are going, the people they are visiting and places they visit, are written in the care plans. The reports from the visits to monitor the quality of the service showed that service users were involved and their care records viewed. Where issues or shortfall arise, these are raised with the Registered Manager to address. 42-44 Lansdowne Road DS0000006439.V347029.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users enjoy a lifestyle that suits them, supported to be involved in the community and have choice of meals. EVIDENCE: Service users said there are not restrictions in how they chose to spend their day, as they completed an application form to attend a college course. One service user has a visitor daily and was planning to visit a relative later that day. Another service user was seen sitting with staff and users of the day room. Service users said they are able to have relationships if they want and staff have supported them to get advice on sexual relationships and contraception. Staff were observed supporting service users such as going shopping with them. Service users seen to be respected by staff when speaking with them or 42-44 Lansdowne Road DS0000006439.V347029.R01.S.doc Version 5.2 Page 14 supporting them. Staff said some service users were out for the day at the ‘Wheel Course’ or participating in activities in the local community. Staff said although service users choose to go out, arrangements are made to ensure they receive their medication timely. Care files read reflected the important people in the lives of the service users such as social workers, family and other professionals. The care plans detailed the service users social interests and goals in relation to employment and education. Information received from the Registered Manager before the site visit stated support is provided in line with the assessment and improvements could be made are in relation to interests expressed by service users. Service users have agreed on a rota for preparing the meals and menu planning. Evening meals are prepared and served at the ‘sister’ home across the road. One service user was seen writing a food shopping list, one for the home and one for themselves. Service user said they manage their own money for shopping for their favourite food and drinks and have their money is in safekeeping in the office. Staff said they support service users in the kitchen when they are preparing meals for everyone’s safety. 42-44 Lansdowne Road DS0000006439.V347029.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 quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users benefit from having their health care needs met, supported with their personal care and medication. EVIDENCE: The care plans have improved by using a ‘person centred’ approach, focusing on the holistic needs and lifestyle of the service users. The plans showed the support needed by the service user, which reflected their wishes, and gave clear direction to staff assisting them. Service user said they were treated with respect by the staff and felt in charge of their life at the home. Service user said they were aware of the contents of their care file and was consistent with the service users surveys responses. Service users living at the home are independent and may need some support, which they make known. Care plans read showed the health professionals involved with the service users such as the General Practitioner and District Nurse, and record kept of the visits made. Records of the medication taken by 42-44 Lansdowne Road DS0000006439.V347029.R01.S.doc Version 5.2 Page 16 service user are written in the plans of care and irrespective of whether the service user is able to manage their own medication. One service user said they have seen the General Practitioner and received additional support and equipment for their daily living. The service user said they visit the Diabetic Nurse regularly and makes sure the meals prepared are suitable. Staff said service users tend to speak with particular staff for support and advice, especially regarding problems or relationships. All medication is stored securely and audited by the contracted Pharmacist and through the quality monitoring visits. Trained senior staff are responsible for administering the medication, staff training records confirmed training in safe handling, and administration of medication was completed. The medication and medication records were viewed for two service users and were found to be in good order. Service users said they get their medication on time and have arrangements in place where the service user is out or returning later than the time for their medication. 42-44 Lansdowne Road DS0000006439.V347029.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 quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are protected by a robust and accessible complaints procedure and by staff trained in safe guarding adult processes. EVIDENCE: Service users when asked were confident that should they have any concerns, they know who to speak with. Service users were aware of how to make complaints and the written complaints procedure, and how to contact Advocacy Services. The complaints procedure is displayed in the reception area along with the new policy known as ‘Ask-Listen-Do’ policy and given to service users when they move to the home. Information received from the Registered Manager before the site visit stated 42-44 Lansdowne Road received 3 complaints. Records showed the concerns were investigated, resolved to the satisfaction of the complainant to benefit the service user and one partially substantiated. The Commission for Social Care Inspection has not received any expressions of concern about 42-44 Lansdowne Road. Survey responses from the service users indicated that they know how to make a complaint and know who to speak with if they were unhappy. Comments received in the service users survey regarding the complaints and who to speak with included: 42-44 Lansdowne Road DS0000006439.V347029.R01.S.doc Version 5.2 Page 18 “Manager/social worker or . . . . . .” “A member of staff” “I think if I have any complaints then I go to the Manager” Staff demonstrated a good understanding of their responsibility and procedures to follow in relation to safeguarding adults and was confident to whistle blow on poor or bad care practices. Staff files read contained evidence to show that staff have received training in safe guarding adults, part of the organisations induction training and attaining a National Vocational Qualification (NVQ) in Care. 42-44 Lansdowne Road DS0000006439.V347029.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, 27, 28 and 30. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users live in a clean home, although improvements to the décor would create a more homely place for service users. EVIDENCE: Service users live in two houses in a residential area. Service users have their own bedroom and have the use of the communal kitchen/dining room and bathrooms. There is no communal lounge and service users were seen using the kitchen/diner, bedroom or the day room used by people using the day services. The Inspector was invited to look at a service user’s bedroom, which was personalised and had bedroom furniture. The service user pointed out that the curtain rail had broken, which was reported to the Registered Manager that morning. The Inspector saw one bedroom having new double-glazing window 42-44 Lansdowne Road DS0000006439.V347029.R01.S.doc Version 5.2 Page 20 installed. Staff said the service user was offered an alternative bedroom to use whilst the double-glazing was installed. Service user said staff made sure food items in the fridge. Service user commented the poor décor and not having the use of a new modern kitchen and bathroom. One service user felt the kitchen was old and did not have a microwave now as it broke. Staff held the same view and said improvements to the décor would create a more homely place for service users and staff. Service users said there is a rota for cleaning and preparation of meals. Staff said that although service users do not want staff to clean their living area, the service users have agreed for staff to clean at least once a week. A service user was seen doing their laundry said it was their laundry day. The laundry room is located away from areas where food is stored and prepared. Staff said some service users may need reminding but generally, service users manage their own laundry. The external grounds to the front of the house are tidy and well maintained. The kitchen/diner and bathrooms although are functional are basic and the décor is dull and dark. All staff have received training in health and safety and infection control. Staff were seen cleaning the kitchen and bathroom using cleaning materials and wearing protective clothing. Staff said service users manage their own personal care and cleaning their living areas although require some prompting and support occasionally. The home has recruited a part-time handyperson who is responsible for minor repairs. The installation of the wet floor has been ordered and this was viewed on the organisations electronic system. The Registered and Deputy Manager confirmed that works identified at the last inspection have been undertaken. The reports from the quality assurance visits identified environmental areas in need for improvement and supported the findings from this visit. The information received from the Registered Manager before the site visit stated the improvement planned for the next 12 months were to the kitchens and bathrooms. Comments received directly from service users and from surveys in relation to the home environment: “The kitchen and bathroom are crap, in need of improvements” “Get windows sorted out and door frames” 42-44 Lansdowne Road DS0000006439.V347029.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): 31, 32, 33, 34, 35 and 36. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are protected by good recruitment processes and staff trained and supervised to care and support the people using the service. EVIDENCE: Staff were aware of their roles and responsibilities, where to find the home’s procedures and who to report any concerns to. Staff said they had completed induction training and special training to working with people with a learning disability and promoting independence. Staff observed used skills that promoted service user’s independence. Staff said that they have ‘handover meetings’ at the change of shift and staff meetings on a regular basis. The minutes of the meetings available and demonstrated staff are informed. Staff confirmed supervision meetings take place on a regular basis, consistent with the survey responses from the staff and the quality assurance visit reports. 42-44 Lansdowne Road DS0000006439.V347029.R01.S.doc Version 5.2 Page 22 The recruitment and selection procedure in place is robust and is supported by a Support Centre in accordance with Craegmoors’ equal opportunity policy and guidance. Staff spoken with described the recruitment process and training completed as part of their induction training. The files of two staff were checked, which contained confirmation of pre-employment checks were in place. The information received from the Registered Manager before the site visit confirmed satisfactory recruitment checks are completed. The information received from the Registered Manager before the site visit, detailed the training provided and planned for staff, which included medication training, moving and handling, food hygiene and first aid. The Deputy Manager confirmed over 60 of the staff had attained National Vocational Qualification (NVQ) level 2 in Care, with a further 7 staff currently doing the NVQ level 2 in care. Service users said they felt that the staff understood their needs. Staff were seen supporting service users and helping them to organise arrangements such as doing their shopping; laundry and visiting a relative. Service users said staff were supportive and available if they needed, which suited their lifestyle. Comments received from the staff surveys: “Our manager is very supportive. We have appraisals every 2 months to discuss our progress and aims” “We have communication book for support workers and communication book for the senior team” 42-44 Lansdowne Road DS0000006439.V347029.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, 40 and 42. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users benefit from having a well-managed service, where they are consulted and systems in place that ensures people are safe. EVIDENCE: The Registered Manager has a number of years’ experience working and managing a residential care home. The Deputy Manager has attained National Vocational Qualification (NVQ) in Care level 3 and said the Registered Manager is completing the NVQ level 4 and the Registered Manager’s Award. The Registered Manager said there are clear roles and responsibilities and senior staff are undertaking specific managerial tasks as part of their further development. 42-44 Lansdowne Road DS0000006439.V347029.R01.S.doc Version 5.2 Page 24 A discussion about the home’s registration certificate was held with the Registered Manager and Deputy Manager. It was confirmed that the named ‘Responsible Individual’ on the registration certificate was no longer in that position. The Registered Manager said the head office would formally notify the Commission. The Registered Manager was advised that the home’s statement of purpose should be updated to reflect the changes. Service user and staff said there is an ‘open door’ policy and people can approach the Registered Manager at any time. Service users were seen popping into the office to speak with the Registered and Deputy Manager with issues that were important to them. Staff confirmed the Registered Manager and senior management team within Creagmoor Ltd are supportive. Clinical Governance Team visits the home to carry out a quality assurance visit that measures the quality of the service against the national minimum standards and the home’s statement of purpose, which sets out the aims and objectives of the service. The report from the quality assurance visit was viewed, which highlighted what the service does well, views of the service users, quality of records and action plan for improvement, such as assessment of needs, care planning, the décor and the home environment. A representative from Creagmoor’s management team, who is external to 4244 Lansdowne Road, visits the home on a monthly basis, representing the Responsible Individual. The reports generated from each visit, demonstrated checks are carried out monthly, detailed the evidence, the findings and the actions required to address any issues. This demonstrated the service selfmonitors and regulates itself to ensure continues to provide a quality service. The information received from the Registered Manager before the site visit stated that policies and procedures are updated at head office and cascaded to the home’s manager via the organisation intranet. Staff knew where to find the policies and procedures. Service user said they were involved in the running of the home and able to discuss with staff any issues about the provision of care individually. Service users meetings are held regularly and the minutes of the meetings are displayed on the notice board. The information received from the Registered Manager before the site visit stated procedures are in place for handling service user’s money. Service user said they manage their finance and have money held in safekeeping, which they can get at anytime. A service user was observed getting their money and signing records that kept a balance of their account. Staff described the procedure and looked at records, which confirmed procedures are in place for handling service users’ finances. 42-44 Lansdowne Road DS0000006439.V347029.R01.S.doc Version 5.2 Page 25 The Deputy Manager said a ‘handyperson’ has been appointed to repair minor faults within the home. The information received from the Registered Manager before the site visit indicated equipment such as fire detection and emergency equipment are maintained and regular fire drills and tests take place. Risk assessments are in place for the home, service users and staff. 42-44 Lansdowne Road has a planned programme of maintenance and records of checks carried out are kept up to date. 42-44 Lansdowne Road DS0000006439.V347029.R01.S.doc Version 5.2 Page 26 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 3 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 3 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 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 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 3 X 3 X 42-44 Lansdowne Road DS0000006439.V347029.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. Refer to Standard Good Practice Recommendations 42-44 Lansdowne Road DS0000006439.V347029.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 42-44 Lansdowne Road DS0000006439.V347029.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!