Inspection on 03/07/07 for 74 Lifstan Way

This inspection was carried out on 3rd July 2007.

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 no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

74 Lifstan Way 29/01/07

74 Lifstan Way 02/03/05

74 Lifstan Way 12/11/04

74 Lifstan Way 22/03/04

Similar services:

Chesham House

Argyll House

Dorset Lodge

Acacia House

Falcon House

Dial House Nursing Home

Cromwell Avenue (9)

Abbey Lodge

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

CARE HOME ADULTS 18-65 74 Lifstan Way 74 Lifstan Way Thorpe Bay Essex SS1 2XE Lead Inspector Mr Trevor Davey Unannounced Inspection 3rd July 2007 10:30 74 Lifstan Way DS0000015445.V344872.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 74 Lifstan Way DS0000015445.V344872.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. 74 Lifstan Way DS0000015445.V344872.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 74 Lifstan Way Address 74 Lifstan Way Thorpe Bay Essex SS1 2XE 01702 466772 01702 613140 lifstanway@together-uk.org www.together-uk.org Together Working for Wellbeing 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) Manager post vacant Care Home 11 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (11) of places 74 Lifstan Way DS0000015445.V344872.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th. January 2007. Brief Description of the Service: 74 Lifstan Way is a detached property which has been refurbished to provide accommodation and personal care for up to eleven adults with a mental disorder. This includes residents aged 18 to 65 years although some are now over 65 years of age since being admitted to the home. The registration category does not include people who may have dementia or a learning disability. The premises are a two-storey detached house in a residential area situated in Thorpe Bay, Southend-on-Sea and is in close proximity to local community facilities and transport links. The accommodation provides single bedrooms, each with its own wash hand basin, shower and toilet ensuite facilities. In addition, there is a separate communal lounge and dining room, kitchen, toilets and bathroom facilities. A shaft lift is available which serves all floors. The home is located in a residential area close to the local shops and bus routes. Residents have the use of a medium-sized garden/patio area. Car parking space is available. The current standard rate of fees is £876 per week as stated in the Service User Guide within the information pack. This figure can vary for individual residents depending on the arrangements agreed with funding authorities. Additional charges are made for hairdressing, toiletries & chiropody. 74 Lifstan Way DS0000015445.V344872.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Key Inspection site visit took place over a period of 5.00 hours and covered all key standards. An assessment was also made of the progress and improvements which had been carried out by the home since the last inspection. The deputy manager together with other staff and residents were spoken with during the site visit. Their comments and contributions received were helpful in assisting the Inspector to prepare this report. There is no registered manager in post and the acting manager is currently on sick leave. As part of the site visit, a tour of the premises took place and some of the personal care records and other official records within the home were also assessed. Since the last inspection, the home has submitted to the Commission for Social Care Inspection their annual quality assurance assessment (AQAA) and the information submitted, has also been taken into account in preparing this report. This form gives homes the opportunity of recording what they do well, what they could do better and what has improved as well as including information of plans for improvement for the next year. The Inspector also provided survey questionnaire forms to give residents the opportunity to express their opinions on the service provided. What the service does well: From observation during the inspection, conversations with staff and residents, there were positive comments to indicate that residents felt they were being listened to and that they had an opportunity to express their views of the service. Monthly meetings and other conversations with residents take place which is part of the process. One of the issues which has been discussed is the choice and variety of meals which has now been improved. The home is good at encouraging independence as much as possible and residents appreciate being able to have the choice of following their own daily routines. This includes visiting day-care facilities and having opportunities to meet socially with friends in the community. Residents are encouraged to take responsibility in the home for carrying out domestic chores. 74 Lifstan Way DS0000015445.V344872.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: There is currently no registered manager in post and although additional management input is being provided for three shifts per week, a permanent arrangement for a full-time manager is necessary for the home. This is to ensure consistent leadership is being provided for the ongoing care and wellbeing of residents in accordance with the policies and procedures of the home. The Statement of Purpose requires updating to ensure that information is correct regarding the management of the home and other details as required by regulation. Although pre-admission assessment procedures are specified in the information pack and Service User’s Guide, these have not always been followed for new residents admitted to the home. This means that suitability of the home and whether it can meet the health and welfare of prospective residents cannot be determined. 74 Lifstan Way DS0000015445.V344872.R01.S.doc Version 5.2 Page 7 The Service User’s Guide contains information for residents about the reporting of abuse or neglect and that all homes should use the local authoritie’s vulnerable adults policy. The Registered Provider’s own policy and reporting procedures for abuse have not, however, been updated and are not compliant with the Public Interest Disclosure Act 1998 and Department of Health Guidance No Secrets. This could place residents at risk. There is no written evidence in the home to show that references or other recruitment checks taken up by Head Office for new staff have been completed. Verbal confirmation by telephone is not acceptable. Infection control procedures should be monitored more closely and regulations relating to the control of substances hazadous to health (COSHH) should be available for staff to refer to. Work place risk assessments should be completed to ensure a safe working enviroment. 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. 74 Lifstan Way DS0000015445.V344872.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 74 Lifstan Way DS0000015445.V344872.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, & 5 People who use the service experience adequate quality outcomes in this area. The Statement of Purpose needs to be updated to give clear information about the home for prospective users of the service. A new Service User’s Guide is available which includes details of fees, terms and conditions of the home. Pre-admission assessment details for care/health needs had not always been completed to give staff suitable information and to assure potential residents that their needs could be met. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The Statement of Purpose has been updated since the last inspection but this still refers to the registered manager although approval has not been given by the Commission for Social Care Inspection and an application is still awaited. A new information pack has been prepared by the Registered Provider which includes a Service Users Guide for every resident. Details of what the service provides, accommodation, and practical living arrangements have also been 74 Lifstan Way DS0000015445.V344872.R01.S.doc Version 5.2 Page 10 included together with information relating to fees, terms and conditions. It is understood that updated individual contracts/license agreements will be given to each resident which will make clear the amount of fees payable and what services these cover. There has been no new admissions to the home since the last inspection. The Registered Provider has policies and procedures for gathering together preadmission information but these have not always been followed previously. Without a thorough needs assessment being completed which takes into account the abilities/knowledge of staff and facilities available, this could lead to prospective residents being inappropriately placed. This could also have a diverse effect for existing residents living in the home. In one case, an application form had been completed for admission to the home but this was undated and unsigned. License agreements were in place and care plans had been reviewed monthly. In the improvement plan submitted by the Registered Provider following the last inspection, it has been confirmed that full preadmission assessments and appropriate visits, will be made to prospective residents in accordance with their own policies and procedures. Feedback from survey forms completed by residents, confirmed that most of them had been consulted about the move into the newly refurbished home but that more information would have been helpful. 74 Lifstan Way DS0000015445.V344872.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, & 9 People who use the service experience good quality outcomes in this area. Residents benefit from continual assessment and consultation reflecting their changing needs which are identified in individual plans. Independent lifestyles are encouraged which are accompanied by risk assessments. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Since the last inspection, a new improved system has been introduced for recording and updating care plans which also includes risk assessments. These have now been updated and are signed by the key worker and resident involved. There is also a chart for staff to complete when monthly evaluations have been completed. Examples of care plans inspected included physical health, mental health and daily living skills as well as finance and relationships. Monthly evaluations had been recorded with the action agreed signed by key workers and individual residents. Care plans were clear in identifying and 74 Lifstan Way DS0000015445.V344872.R01.S.doc Version 5.2 Page 12 described the current situation, the action required and how the plan will be measured. Samples of risk management forms were inspected which included skin care and again, these had been signed and agreed by residents. This demonstrates that residents are consulted and fully involved in care planning including any changes which may be necessary for their protection and improved quality of life. Residents spoken with confirmed that key workers were supportive in discussing personal needs. Residents who were willing to talk to the Inspector confirmed that regular meetings take place and staff talk to them regarding changes in the home and their preferred daily routines. They are able to choose and enjoy independence so far as this is possible. Residents confirmed that they all have keys to their own rooms and staff respect their privacy. The home has also acknowledged in their AQAA selfassessment form, the need for key workers to be more involved in the care planning of all residents which would provide more continuity of practice when staff are off duty or on holiday. 74 Lifstan Way DS0000015445.V344872.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): 12,13,15,16 & 17 People who use the service experience good quality outcomes in this area. People living at the home are encouraged to take part in a range of activities which reflects our lifestyle to meet individual social and cultural needs. People living at the home benefit from a variety of healthy and well presented meals. This judgement has been made using available evidence including a visit to theservice. EVIDENCE: The home provides support to residents in pursuing social and recreational activities in accordance with individual needs and choices. Since the last inspection, more discussions have taken place with residents both in meetings and also on a one-to-one basis. Residents spoken with mentioned that they have been to local theatres as well as pub meals with staff. Others attend local day centres and clubs during the week to play snooker and board games. 74 Lifstan Way DS0000015445.V344872.R01.S.doc Version 5.2 Page 14 They enjoyed the opportunity of meeting other people and making friends during these weekly activities. Some of the residents are accompanied by staff to the local shops and they also enjoy pub lunches. The staff team are also in the process of discussing holiday arrangements for groups of residents. Some the residents said they would like to have more parties and music entertainment. Residents confirmed that there is now a better choice and variety of meals which has improved following discussions with staff. They can also have snacks at different times during the day. Special birthday cakes are also prepared. The chef confirmed that residents have been involved in looking at additional items for menus with greater variety and choice including vegetarian meals. Residents have also been involved in discussing alternative deserts which include gateauxs, cheesecakes, crumbles and a selection of fresh fruit. Alternative diabetic food plus the use of low-fat milk and sugar substitute is now also available. Most of the food is prepared in the home and cooked rather than using ready prepared meals. There are alternative choices available. Records of meals provided to individual residents were available for inspection. The home has been able to demonstrate that there is now more consultation with residents to discover their preferences regarding their home environment, daily routines and social aspirations. The management have commented in their AQAA self assessment form, that it is their intention to ensure staff work along side residents to find out more information regarding other activities which may be available. 74 Lifstan Way DS0000015445.V344872.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 & 20 People who use the service experience good quality outcomes in this area. The personal, physical and emotional health needs of residents were being met appropriately taking account of preferred support required. Medication and administrative procedures were in place to ensure the safety and protection of residents. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Residents spoken with felt confident with the way staff interact and support them which includes accompanying individuals to attend health care appointments. Personal care records sampled, confirmed that residents had been involved in discussing their health needs and how these should be addressed. Since the last inspection, a new system has been introduced for the recording of health care appointments but not all entries had been completed. Medilogs are now available on individual files but there needs to be a consistency in practice which clearly shows details of health care 74 Lifstan Way DS0000015445.V344872.R01.S.doc Version 5.2 Page 16 appointments and the treatment provided. The home have made reference in their AQAA self-assessment form, that more support from outside services is needed as residents get older and visits from health care professionals are sometimes irregular and patchy. Since the last inspection, improvements have been made in the medication administrative records (M.A.R.) and clear prescription details are now being provided by local doctors. From the sample checks made, staff are abiding by the policies for administering medication safely in the home. 74 Lifstan Way DS0000015445.V344872.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 & 23 People who use service experience adequate quality outcomes in this area. People who use the service have the opportunity to express their concerns and have access to a robust, effective complaints procedure. The home’s policy for the prevention of harm to vulnerable adults is not compliant in accordance with the Public Interest Disclosure Act 1998 and Department of Health guidance No Secrets, which could pose a risk to residents. This judgement has been made using available evidence including a visit to the service. EVIDENCE: An effective complaints procedure is in place and since the last inspection, an information sheet explaining the process, has been included in the new Service User’s Guide. A copy of the procedure is also on the homes noticeboard. Residents spoken with, were aware of how to make a complaint and confirmed that the procedure had been explained to them. Residents also said that they feel safe and secure in the home and staff are kind. Staff spoken with had an understanding of the reporting procedures to be followed in cases of abuse or where this was suspected. The updated Service Uses Guide explains to residents that anyone who uses its services has the right to protection from harm and abuse. People who residents can speak to are also listed and it is specified that all agencies should use the local 74 Lifstan Way DS0000015445.V344872.R01.S.doc Version 5.2 Page 18 authoritie’s vulnerable adults policy. However, the Registered Providers policy and procedure manual is still not compliant and gives the wrong information which is contrary to the statutory requirements laid down which was referred to in the last inspection report. In their response to the improvement plan issued following the previous inspection, the home states that the Area Manager is currently consulting with the Registered provider to clarify how the policy and procedures manual can be updated. This means residents in the home could be vulnerable and that there is a risk that such incidents may not be referred to the local authority adult protection unit or other agencies concerned. 74 Lifstan Way DS0000015445.V344872.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 & 30 People who use the service experience good quality outcomes in this area. The premises are well maintained to enable people who use the service to live in a safe, comfortable environment. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Residents spoken with, confirmed that they liked their newly refurbished home and the accommodation which had been provided. Accommodation and facilities have been provided which comply with the National Minimum Standards relating to care homes for adults. The management are working with contractors to deal with any outstanding maintenance issues which have arisen since refurbishment of the building. Where there are sensory impairments, special arrangements have been made for modifications and devices to be fitted to alarm systems to enable residents to respond appropriately. Risk assessments have been completed as a result of residents 74 Lifstan Way DS0000015445.V344872.R01.S.doc Version 5.2 Page 20 who have a tendency to wander from the home which may pose a risk to themselves. Modifications to the security arrangements of the front door are being put in place to safeguard vulnerable residents whilst at the same time, not infringing the rights of those residents who wish to go out. Since the last inspection, paper towels are being used together with liquid soap dispensers to minimise the spread of infection in the home. Safety data sheets are also used but the home should obtain copies of the regulations for the control of substances hazardous to health (COSHH) to ensure the safe use of these materials and to regulate secure storage areas. Cleaning procedures are followed but when looking around the premises, one bathroom/shower area had not been thoroughly cleaned. Closer monitoring and supervision by management should take place of cleaning procedures in the home to minimise potential risk of infection. 74 Lifstan Way DS0000015445.V344872.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34 & 35 People who use the service experience adequate quality outcomes in this area. Staff in the home are trained, and in sufficient numbers to support people who use the service. Recruitment procedures and practices are not sufficiently robust to ensure residents are properly supported and protected. This judgement has been made using available evidence including a visit to the service. EVIDENCE: A rota was available showing the named staff on duty. This consisted of the deputy manager, senior and other care workers. An agency chef and cleaner are also employed five days a week. There is always a minimum of one senior and one care worker on duty to support residents but staff are flexible and additional hours are provided where residents need to be accompanied for various social outings and health-care appointments. The home are attempting to recruit two night support workers to be on awake duty but at the time of the inspection, one member of staff is rostered to sleep in on the 74 Lifstan Way DS0000015445.V344872.R01.S.doc Version 5.2 Page 22 premises and to be available to give assistance if required. Staff relate well to residents and are supportive in the support and care they provide. Since the previous inspection, training has been discussed in a staff meeting. Issues regarding training are also discussed the supervision. Details of the learning and development programme from the Registered provider were available and members of staff are able to apply for courses of training. Local courses are also available which staff had completed including first aid and food hygiene. The staff have expressed a need to have diabetes training and arrangements were made but unfortunately, this never took place. New arrangements are to be made as soon as possible as this is a need for the staff team. At the time of inspection, a number of staff had completed or were nearing completion N.V.Q. Level 3 Adult Care. Other staff had completed Level 2 and one Level 4 of the N.V.Q. The staff recruitment records have been reorganised since the previous inspection and evidence of Criminal Record Bureau checks taken up for staff, was available. Application forms, proof of identification, appraisal and supervision records were also in place. It is understood that the Registered Provider, through the Human Resources section, are responsible for taking up references for new staff. However the only confirmation given to the home that these have been processed and are acceptable, is by a telephone call and there is no written evidence to indicate that satisfactory references have been received. This could place residents at risk unless there is written confirmation that all recruitment checks have been completed. 74 Lifstan Way DS0000015445.V344872.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): 37,39 & 42 People who use the service experience adequate quality outcomes in this area. The management input needs to be consistent to ensure the development of the home meets its stated purpose, aims and objectives. Procedures are in place to monitor the health, safety and welfare of residents. This judgement has been made using available evidence including a visit to the service. EVIDENCE: An application for registration of a manager for this service has not been received by the Commission for Social Care Inspection. It is understood that the current acting manager is still on sick leave. In addition, a deputy 74 Lifstan Way DS0000015445.V344872.R01.S.doc Version 5.2 Page 24 manager from another service has been involved in the home for three shifts per week and is currently taking the acting manager’s role. She is also contactable by telephone. Part of this role includes involvement with meetings relating to care planning as well as staff meetings. It is understood that this is for a three-month period. There has been some improvement in the daily routines and practices affecting the daily operation of the home. Care plans are now consistent in the way they are presented and recorded. The organisation and documentation of other personal care records had improved. Monthly visit reports by the Responsible Individual were available for inspection as required under Regulation 26. Issues regarding shortcomings in health and safety are being addressed and additional training is being provided to staff as required. Although some safe environment work place risk assessments had been completed, this task needs to be completed. Some measures have been taken to improve warning devices in the home for the protection of residents. Staff and residents have been through fire evacuation procedures which are recorded. The AQAA self-assessment form completed by the home acknowledged that all staff are involved in the running of the home and are learning continuously. Although new ideas are continuously being discussed, no specific key objectives have been identified for improvement in the next twelve months. Although the staff team work well together, good leadership and management skills are not available in the home on a regular basis. Feedback from quality assurance surveys and monitoring of the service, does not identify how the service is to be developed to achieve ongoing improvements in the home and the quality of life for residents. 74 Lifstan Way DS0000015445.V344872.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 3 x 4 x 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 x 3 x x 2 x 74 Lifstan Way DS0000015445.V344872.R01.S.doc Version 5.2 Page 26 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4 Requirement Timescale for action 30/09/07 2. YA2 14 The Registered Person shall compile an up -todate Statement of Purpose for the home incorporating matters as listed in Schedule 1 and a copy of this statement shall be sent to the Commission for Social Care Inspection. (Previous timescale of 30/04/07 not met) The Registered Person 30/09/07 shall not provide accommodation to a prospective resident unless there has been a full pre- admission assessment and appropriate consultation/visits, to ensure that the care home is suitable for the purpose of meeting the prospective resident’s health and welfare. 74 Lifstan Way DS0000015445.V344872.R01.S.doc Version 5.2 Page 27 3. YA5 5A/B The Registered Person 30/09/07 shall provide to each resident a statement setting out the contract/terms and conditions, specifying the fees payable and the services provided by the home, in accordance with this regulation (as amended). This information to be included with the Service User’s Guide. (Previous timescale of 30/04/07 not met) The Registered Person 30/09/07 shall make arrangements for ensuring the procedure for preventing abuse and reporting procedure is compliant with the Public Interest Disclosure Act 1998 and Department of Health Guidance No Secrets. Arrangements must also be made for staff to be made aware of these changes and for any additional training to be provided as required. (Previous timescales of 31/04/05 & 31/03/07 not met). The Registered Person shall not employ a person to work at the care home unless all recruitment checks have been completed which includes evidence of two satisfactory written references. (Previous timescale of 31/03/07 not met). The Registered Person shall appoint an individual DS0000015445.V344872.R01.S.doc 4. YA23 13(6) 5. YA34 19 30/09/07 6. YA37 8 &9 30/09/07 74 Lifstan Way Version 5.2 Page 28 to manage the care home who has the qualifications, skills and experience necessary for managing the home on a day- to day basis. (Previous timescale of 30/04/07 not met) 7. YA42 13(4) The Registered person shall ensure that all parts of the home to which residents have access are so far as reasonably practicable, free from hazards to their safety and appropriate work place risk assessments are in place and reviewed as required.(this includes having regard to C.O.S.H.H. regulations, necessary).(Previous timescale of 30/05/07 not met) 30/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Good Practice Recommendations Standard YA19 Arrangements should be made to improve the availability of professional health care support for residents. YA19 Health care support & appointments should be clearly documented on a regular basis in personal care records. YA30 Closer supervision & monitoring should be carried out of cleaning/hygien routines in the home. 74 Lifstan Way DS0000015445.V344872.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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. 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