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Inspection on 13/09/05 for 55 Lincoln Avenue

Also see our care home review for 55 Lincoln Avenue for more information

This inspection was carried out on 13th September 2005.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Services provided to customers at Lincoln Avenue, is person centred. Good practice and customer safety is promoted. Customers are consulted about the care they receive through informal customer meetings, consultation on a daily basis, customer quality questionnaires and link meetings, which are for family of Lincoln Avenue customers . Staff and customer records are stored in secure locations in the home and are in good order. Staff learning and development is promoted, and a good system is in place to ensure that all staff at Lincoln Avenue are kept up to date, well trained and are competent in their role. This is also evident from the numbers of staff who have achieved and are working on their NVQ awards. The personal relationships course, which is provided to Local Authority customers, which was happening at the time of inspection, shows how customers, their views and feelings are valued. Customers who were spoken to told the inspector about the activities they undertake while at Lincoln Avenue, it was clear that activities for customers are tailor made to meet their personal interests and likes. The home is clean and tidy and has a warm and homely atmosphere. The senior support worker, who facilitated the inspection, was knowledgeable about the expectations of their role, the service provided to customers and the customers needs.

What has improved since the last inspection?

Self-assessment forms are now provided to customers to ensure that respite allocations are made fairly, for example weekend respite care is offered to all customers who require it. Lincoln Avenue provides its customers with a Provider Review, which is in a `user friendly` format including picture symbols as well as written text. This provides the opportunity for customers to state what they think of the service they receive and for Lincoln Avenue to assess the quality of service they provide to customers.

What the care home could do better:

No requirements or recommendations have arisen out of this inspection of the home.

CARE HOME ADULTS 18-65 55 Lincoln Avenue Ash Rise Saxmundham Suffolk IP17 1BY Lead Inspector Julie Small Unannounced Inspection 13th September 2005 11:50 55 Lincoln Avenue DS0000037694.V249895.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 55 Lincoln Avenue DS0000037694.V249895.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. 55 Lincoln Avenue DS0000037694.V249895.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 55 Lincoln Avenue Address Ash Rise Saxmundham Suffolk IP17 1BY 01728 603148 01728 603125 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) Suffolk County Council Ms Debbie Cole Care Home 3 Category(ies) of Learning disability (3), Physical disability (3) registration, with number of places 55 Lincoln Avenue DS0000037694.V249895.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th December 2004 Brief Description of the Service: Lincoln Avenue is a respite home, where short-term respite care is provided to up to three adults who have learning disabilities, some may also have physical disabilities. Lincoln Avenue is a Local Authority Home, who rent the property from Heritage Housing Association. The house is situated on a housing estate and is near to the local amenities on offer in Saxmundham town centre. 55 Lincoln Avenue DS0000037694.V249895.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on Tuesday 13th September 2005 from 11.50 to 15.40. Julie Small undertook the inspection. Rachel Wood, the senior support worker facilitated the inspection. All information requested during the inspection was provided promptly and confidently. The senior support worker informed the inspector that the people who receive a service at Lincoln Avenue are referred to as customers; this will be used throughout the report. At the time of the inspection there was a personal relationships course for customers of the Local Authority. Two customers who use services at Lincoln Avenue were present and were spoken to by the inspector. The inspector spoke to the course facilitator, about the contents of the course provided to customers. One member of staff who was at Lincoln Avenue working on their National Vocational Qualification (NVQ) award was spoken to about their award. Staff and customer records were viewed and a tour of the home was undertaken. What the service does well: Services provided to customers at Lincoln Avenue, is person centred. Good practice and customer safety is promoted. Customers are consulted about the care they receive through informal customer meetings, consultation on a daily basis, customer quality questionnaires and link meetings, which are for family of Lincoln Avenue customers . Staff and customer records are stored in secure locations in the home and are in good order. Staff learning and development is promoted, and a good system is in place to ensure that all staff at Lincoln Avenue are kept up to date, well trained and are competent in their role. This is also evident from the numbers of staff who have achieved and are working on their NVQ awards. The personal relationships course, which is provided to Local Authority customers, which was happening at the time of inspection, shows how customers, their views and feelings are valued. Customers who were spoken to told the inspector about the activities they undertake while at Lincoln Avenue, it was clear that activities for customers are tailor made to meet their personal interests and likes. The home is clean and tidy and has a warm and homely atmosphere. The senior support worker, who facilitated the inspection, was knowledgeable about the expectations of their role, the service provided to customers and the customers needs. 55 Lincoln Avenue DS0000037694.V249895.R01.S.doc Version 5.0 Page 6 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. 55 Lincoln Avenue DS0000037694.V249895.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 55 Lincoln Avenue DS0000037694.V249895.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4 Customers can expect that their individual aspirations and needs will be assessed and met. They will be provided with an opportunity to visit and ‘test drive’ the home. EVIDENCE: Lincoln Avenue provides short-term respite care for customers; customers often view this as a holiday. Customer records viewed show a clear needs assessment and care plan for each customer. Individual packages of care for each customer are present in records. Agreements of service were present in the two customer files viewed. As well as the homes’ and the purchasing organisation assessment, parents and carers are invited to complete a selfassessment form, which are analysed and used to work out allocations of the service, which represent the customer’s needs. This ensures that all customers are provided with fair access to the respite care provided, for example weekend care. Allocations also take into account if customers have met and become friends during a previous respite visit, then if the customer wishes, they can have future respite which coincides with their friends respite care. When referrals for respite care are received by Lincoln Avenue, customers and their family are invited to visit the home, to look around and to share information. During the visit customers are provided with an induction pack, including the complaints procedure, a blank care plan and user guide, which are written in a way, which is accessible to customers. Prospective customers are then invited to visit Lincoln Avenue for tea, and are then invited to sleep 55 Lincoln Avenue DS0000037694.V249895.R01.S.doc Version 5.0 Page 9 over. This is so customers may ‘test drive’ the service. Two customers were spoken to, both stated that they are happy when they receive respite care from Lincoln Avenue and that Lincoln Avenue meets their needs. One customer stated ‘they help me a lot’. Both customers told the inspector dates of their next visit to Lincoln Avenue, how long they are staying and what they expect from the time they will be at Lincoln Avenue. This suggested that customers are consulted about the service they will receive and know what to expect. 55 Lincoln Avenue DS0000037694.V249895.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 8, 10 Customers can expect that their assessed and changing needs and personal goals are reflected in their individual plan. Customers can be assured that they are consulted on, and participate, in all aspects of life in the home and that information about them is handled appropriately, and their confidences are kept. EVIDENCE: Two customers were receiving a service from Lincoln Avenue at the time of inspection, these two customers records were viewed. Care plans are in place for customers, these are clear and are updated regularly. The care plans are clearly generated from the needs assessments undertaken. The care plans include customers preferred form of communication, seizures information, behaviour, medication, room allocation and care the customer requires on a daily basis. One customer’s records contained minutes of a visit to the home by a speech therapist to assist staff in communicating with the customer, and a speech and language report. Customer files viewed are in a format which is accessible to customers, for example a provider review which customers complete when they have received respite care at Lincoln Avenue is in picture, symbol and written format. Records are stored in a secure place within the 55 Lincoln Avenue DS0000037694.V249895.R01.S.doc Version 5.0 Page 11 home; only staff have access to customers personal records, unless customers wish to read their own records. Care plans are completed in consultation with customers and their family. Customers complete regular provider reviews, which identified what aspects of the care received at Lincoln Avenue customers are satisfied and dissatisfied with, family and carers self assessment report and regular Link meetings for families provide feedback and information with regards to care plans, the running of the home and the service received by customers. Throughout the inspection it was clear that customers are consulted with and are provided with choice throughout their care at Lincoln Avenue. Records viewed show how customers make individual choices. Customers attend informal customer meetings while at Lincoln Avenue to discuss the running of the home. The complaints procedure viewed provides customers with an accessible document, which includes pictures and written text. Two customers spoken to said that they are offered choice in what they do such as activities. One customer said that they cook dinner and go shopping to choose what they will eat. 55 Lincoln Avenue DS0000037694.V249895.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 14, 15, 16, 17 Customers can expect to be provided with opportunities for personal development and to take part in appropriate activities. Customers have appropriate relationships and their rights are respected in their daily lives. Customers can be assured that they will be offered a healthy diet and enjoy their meals and mealtimes. EVIDENCE: Two customers spoken to both said that the food is good at Lincoln Avenue. One customer said that staff do them a packed lunch for when they go to college, and that they go out for a meal or a snack sometimes. One resident also said that they have tea out sometimes. The resident said that sometimes they cook, ‘I can cook spaghetti Bolognese and shepherds pie and I go shopping so I can cook the food’. Menu’s were viewed, the menu’s offered provide a healthy diet. Staff spoken to said that fresh fruit and vegetables are encouraged. Customers choose their own menu at the beginning of their respite care and they are included in the shopping for the items chosen. This is reflected in the menus, which show, on some days, that customers have different meals. Meals are served in the 55 Lincoln Avenue DS0000037694.V249895.R01.S.doc Version 5.0 Page 13 dining room, which is open plan, with the lounge and kitchen. The dining area is light, well ventilated and overlooks the conservatory and garden. At the time of the inspection several individuals were using the premises for a personal relationship course. Two of the individuals were customers of Lincoln Avenue, one of the customers who were spoken to said ‘they are great trainers, great with us, they are very kind people’. One of the facilitators to the course was spoken to regarding the contents of the course. The Local Authority funds the training and customers who attend the course have expressed an interest in attending. The course is over twenty sessions and issues include assertiveness, likes and dislikes, what is abuse, what to do if you are unhappy about something, knowing your own body, how babies are born and sexual relationships. The facilitator stated that participants take responsibility for making teas and coffees and cleaning up the room when they have finished. This was observed at the time of the inspection. If customers have met and became friends during respite at Lincoln Avenue, or friends use the service, if customers request it, effort will be made by Lincoln Avenue to provide allocations at coinciding times. Friends and family are allowed to visit customers at Lincoln Avenue. Staff spoken to said that one customer has recently begun visiting family members while at Lincoln Avenue, as the customer’s usual home is too far to visit the relatives. Customers already have identified work or college placements when they attend Lincoln Avenue for respite care, they are encouraged to continue with their usual placements while at Lincoln Avenue. Two customers spoken to listed their activities while at Lincoln Avenue. Both were very different and reflected the customers interests, which show that activities are ‘tailor made’ for each customer. One customer said that they go to Great Yarmouth for the day, go shopping, have snacks out and do jigsaws. One customer said that they go bowling, go out to tea, go to the pub, if it’s raining they watch videos, play on the play station, cook and built a Dr Who scrapbook. The customers said they enjoyed their activities and if they could do anything they liked, could not think of anything further they could do at Lincoln Avenue. Two customers spoken to said that staff always knocks their bedroom door and ask if they can come in before entering. Staff spoken to said that customers can have the use of their bedroom key if they wish, or they can ask staff to lock and unlock their door. Customer records viewed show that customer’s daily routines promote independence. Staff spoken to said that customers plan what they are going to do at the beginning of their respite care, for example making the bed or doing their laundry. This is encouraged if the customer does not participate in the bed making or laundry, as they had made an agreement at the beginning of 55 Lincoln Avenue DS0000037694.V249895.R01.S.doc Version 5.0 Page 14 the respite care. 55 Lincoln Avenue DS0000037694.V249895.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): 19 Customers can expect that their physical and emotional health needs are met. EVIDENCE: Two customer records viewed showed detailed care plans regarding their health and emotional needs, each aspect of care also has a risk assessment. Medical appointments and issues are well documented. One customer records show a report from speech and language therapy, and minutes from a speech therapist visit to Lincoln Avenue to assist staff in communicating with the customer. Customers can access the personal relationship course, if they wish to find out about relationships, contraception and services available to them. 55 Lincoln Avenue DS0000037694.V249895.R01.S.doc Version 5.0 Page 16 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): 22 Customers can expect that their views are listened to and acted on EVIDENCE: Lincoln Avenue provides a complaints policy and procedure, which was viewed. The complaints procedure is provided to customers in an accessible format, having picture symbols as well as written text. The complaints log was viewed; there has not been a complaint since 2003. The logbook consists of the date of the complaint, what it was, reference number, acknowledgement, actions to be taken and completion date. The procedure is clearly explained in the complaints log for the attention of staff. Staff spoken to stated that if there are any issues customers wish to discuss they can discuss and action with staff or discuss the issue in an informal customers meeting. This is recorded and stored in customer’s files. The provider review form, which asks customers views on the service they receive, has an action column, for issues where a customer complains or raises a concern about the service they receive. These forms are filed and kept at Lincoln Avenue. Link meetings are available for customer’s family to discuss the service they receive. Two residents spoken to said they have never complained about Lincoln Avenue, but know they can speak to staff if they are not happy, they said they have the complaints procedure. 55 Lincoln Avenue DS0000037694.V249895.R01.S.doc Version 5.0 Page 17 All records viewed and procedures for quality assurance regarding the provision of service at Lincoln Avenue show that feedback about the service is actively sought and valued. 55 Lincoln Avenue DS0000037694.V249895.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): 27, 30 Customers can expect that toilets and bathrooms provide sufficient privacy and meet their individual needs and that the home is clean and hygienic. EVIDENCE: Lincoln Avenue provides a downstairs, which is en suite to the downstairs bedroom, and an upstairs bathroom each with a toilet. There is also a downstairs toilet. Both bathrooms are large with a ‘walk in shower’. Staff spoken to said that Lincoln Avenue used to have baths, but customers said that they would provide showers. The staff said that the showers promote independence, customers can have showers without the support they would need from staff if they used a bath. The downstairs bathroom provided a shower seat, both bathrooms have grab rails. Anti bacterial hand wash gel and wet wipes are provided in bathrooms and the toilet. The toilet provides paper towels in a holder and a bin with a lid on. There are sanitary bins in the downstairs toilet and the upstairs bathroom. Lincoln Avenue is clean and free from offensive odours. The laundry is separate from the kitchen area. The washing machine washes up to 95 degrees; there is also a chemical sluice in the washing machine to wash low temperature clothing. Hand washing facilities and anti bacterial hand wash gel are available in the sluice area. 55 Lincoln Avenue DS0000037694.V249895.R01.S.doc Version 5.0 Page 19 Lincoln Avenue provides lockable cupboards for COSHH (control of substances hazardous to health) items; the inside of the cupboard door provides procedures for working with substances. Storage of foods in the kitchen area was appropriate. Each food item, which was opened in the refrigerator, had a label with the time and date of opening. A recent environmental health check was undertaken a month ago, the certificate for this was viewed. 55 Lincoln Avenue DS0000037694.V249895.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): 32, 34, 35, 36 Customers can expect that they are supported by appropriately trained; competent, qualified, well supported and supervised staff. Customers can be assured that they are supported and protected by the home’s recruitment policy and practices. EVIDENCE: Two customers spoken to said that they liked the staff at Lincoln Avenue, and that they meet their needs. One customer said ‘they are nice people, they help me a lot’. The customers spoken to said that they could talk to staff and feel comfortable with staff at Lincoln Avenue. The senior support worker is currently working on NVQ level 4 in care, which should be complete by January. Four staff have achieved their NVQ level 3, two staff are working on their NVQ level 3, and are should be completed by the end of the year. Two staff have applied to do, and will be shortly, their NVQ level 3. Lincoln Avenue has eight permanent staff members and use eight regular relief staff. NVQ achievement will place Lincoln Avenue almost achieving the target of 50 staff to have achieved NVQ award by 2005. One member of staff was observed to be working on their NVQ award; a colleague was completing a witness testimony for them. The staff members were spoken to, one staff said that they had enjoyed doing their NVQ and only had two units left to do. One staff member said that they had applied to do 55 Lincoln Avenue DS0000037694.V249895.R01.S.doc Version 5.0 Page 21 their NVQ and were looking forward to completing it. Staff records viewed, showed individual training plans for staff members. Staff interest in a particular course is recorded and why they may find this useful in the work that they do. When training has been completed by members of staff is recorded and dates for future courses. All staff have completed their TOPSS (now Skills for Care) induction and foundation training, which is provided by the local authority. Records show training courses attended include, personal care, epilepsy care, food hygiene, safety at work, ‘unisafe’ theory and practice, abuse and neglect, worker development, infection control, emergency first aid, manual handling, understanding needs (learning difficulty), principles of care, confidentiality, in house policy, COSHH, value of care, communication, makaton, value base, fire safety, challenging behaviour, vulnerable adults awareness and sexuality. Staff records clearly show that staff members are provided with a robust training programme, which supports their performance in the service they provide to their customers. There was a timetable observed on the office wall, which indicates when staff are due to attend refresher training on each programme, for example manual handling. Staff records show supervision programmes for staff members. Supervision is provided to staff at least on a two monthly basis. Each supervision record has a supervision agreement attached, which is signed and dated by both the supervisor and the supervisee. Staff rotas were viewed, these showed that staff are available on an at least two customers to one member of staff at all times. The rota highlights when staff are at work with customers, where they are attending training programmes and leave. Lincoln Avenue currently has eight permanent staff, including managers, one administration staff and eight regular relief staff. On the day of the inspection there had been a team meeting, staff spoken to stated that team meetings are regular and staff are informed of any compliments or comments received from customers at these. Two staff records viewed provided a photograph of the staff member, criminal record check, protection of vulnerable adults check, copy of birth certificate, two written references, a signed induction pack, interview checklist, application form, showing a career history and authorisation for appointment. Records viewed show that customers are supported and protected by Lincoln Avenues recruitment procedures. 55 Lincoln Avenue DS0000037694.V249895.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): 39, 41 Customers can expect that the home provides a robust quality assurance system and that their rights and best interests are promoted and protected. EVIDENCE: Lincoln Avenue provides a robust system of quality assurance. Customers are provided with a Provider Review, which were viewed, where customers can comment on the service they receive if they wish. The Provider Review contains an action section where Lincoln Avenue may action any dissatisfaction with the service customers may raise. Regular Link meetings occur where customer’s family can discuss and comment on the service they receive from Lincoln Avenue. Inspection reports, the homes policies and procedures and any information about proposed work at Lincoln Avenue is provided and discussed. All records viewed were well kept, up to date and in good order. All customer records were accessible to them and provided written text and picture symbol 55 Lincoln Avenue DS0000037694.V249895.R01.S.doc Version 5.0 Page 23 format. All records are kept in a secure place at Lincoln Avenue; this was observed when requests for records from the inspector were made. 55 Lincoln Avenue DS0000037694.V249895.R01.S.doc Version 5.0 Page 24 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 X 3 3 3 X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 4 X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score X X X 3 X X 3 LIFESTYLES Standard No Score 11 3 12 X 13 X 14 4 15 4 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 4 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 55 Lincoln Avenue Score X 3 X X Standard No 37 38 39 40 41 42 43 Score X X 3 X 3 X X DS0000037694.V249895.R01.S.doc Version 5.0 Page 25 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. Refer to Standard Good Practice Recommendations 55 Lincoln Avenue DS0000037694.V249895.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 55 Lincoln Avenue DS0000037694.V249895.R01.S.doc Version 5.0 Page 27 - 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!