Inspection on 09/05/05 for 97 Luncies Road

This inspection was carried out on 9th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

97 Luncies Road 24/04/07

97 Luncies Road 27/02/06

97 Luncies Road 03/10/05

97 Luncies Road 01/11/04

97 Luncies Road 23/01/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

Care Homes For Adults (18 – 65) Luncies Road (97) 97 Luncies Road Basildon Essex SS14 1SD Unannounced Inspection 9th March 2005 Commission for Social Care Inspection Launched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: • Promote improvement in social care • Inspect all social care - for adults and children - in the public, private and voluntary sectors • Publish annual reports to Parliament on the performance of social care and on the state of the social care market • Inspect and assess ‘Value for Money’ of council social services • Hold performance statistics on social care • Publish the ‘star ratings’ for council social services • Register and inspect services against national standards • Host the Children’s Rights Director role. Inspection Methods & Findings SECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Luncies Road (97) Address 97 Luncies Road, Basildon, Essex, SS14 1SD Email address Tel No: 01268 555488 Fax No: 01268 555488 Name of registered provider(s)/company (if applicable) Walsingham Name of registered manager (if applicable) Type of registration Care Home No. of places registered (if applicable) 5 Category(ies) of registration, with (number of places) Learning disability (5) Registration number I060000272 Date first registered 30th July 2002 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspection Date of latest registration certificate 7th August 2003 YES YES 01/11/04 If Yes refer to Part C Luncies Road (97) Page 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 3 9th March 2005 08:30 am Mrs Michelle Love N/A N/A N/A N/A Ms Hilary Ager, Acting Manager ID Code 072088 Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspection Luncies Road (97) Page 2 CONTENTS Introduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspector’s Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 – 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Provider’s Response Provider’s Comments Action Plan Provider’s Agreement Luncies Road (97) Page 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Luncies Road (97). The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: • Inspection methods used • Key findings and evidence • Overall ratings in relation to the standards • Compliance with the Regulations • Required actions on the part of the provider • Recommended good practice • Summary of the findings • Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates. Luncies Road (97) Page 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. 97 Luncies Road is a care home providing personal care and accommodation fro up to five adults with a learning disability. The home is a two storey detached residence, which was originally built in the 1970s as a children’s home, and was later, in 1989 refurbished and registered as a Christian based home run by Walsingham. The home’s facilities include a living room and separate dining room and each service user has their own single room. There is a spacious garden with a separate patio area. The home is situated at the end of a no through road next to a private housing estate and is located close to local shops and Basildon town centre. It is within walking distance of public transport facilities. Luncies Road (97) Page 5 PART A SUMMARY OF INSPECTION FINDINGS Inspector’s Summary (This is an overview of the inspector’s findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This inspection was undertaken on 9th March 2005 at 08.40 a.m. by Michelle Love, Inspector. This service has been inspected as required under the Care Standards Act 2000 and the Care Homes Regulations 2001 (as amended). Areas to be progressed are listed in the Requirements and Recommendations section of the report. Any breaches in regulations that pose a more immediate risk to service users have been highlighted for urgent action. Not all standards were examined during this inspection. Standards not considered on this occasion will be assessed at the home’s future inspection. Where policies and procedures are acknowledged as being in place, these have not necessarily been read or commented on in depth. Future inspections may therefore identify further areas to review and address. From 1st April 2004 the work and responsibilities of the National Care Standards Commission have transferred to the new Commission for Social Care Inspection (CSCI). Rapport between support staff and service users was observed to be positive, caring and sensitive. Support staff demonstrated a good understanding of service users needs and personal preferences. Choice of Home (Standards 1-5) Two out of two standards assessed were met Since the last inspection no new service users have been admitted to the care home. It is positive to note that the organisation remains committed to provide training for all members of staff. Statement of Terms and Conditions for service users have been revised and reissued, and now use simple language and are pictorial. Individual Needs and Choices (Standards 6-10) Three out of three standards assessed were met On inspection of one service user care plan and risk assessments, these were seen to be detailed and comprehensive. Wherever possible service users continue to be encouraged and empowered to participate within the running of the home. Lifestyle (Standards 11-17) Four out of four standards assessed were met Luncies Road (97) Page 6 Service users are encouraged to maintain and develop independent living skills. Records indicate that regular activities are provided and undertaken by service users within the home environment and local community. The home continues to operate an `open visiting policy`. Pictorial aids are available to enable service users to make choice pertaining to snacks, drinks and meals provided at Luncies Road. Nutritional records indicated that a varied range of meals is provided to service users. Personal and Healthcare Support (Standards 18-21) Three out of three standards assessed were met Service users have access to a wide range of healthcare services/professionals. The homes medication records and storage facilities were observed to be satisfactory. Issues highlighted at the last inspection had been addressed. Information pertaining to funeral arrangements/terminal care for service users were clearly documented. Bereavement counselling is available for both support staff and service users. Concerns, Complaints and Protection (Standards 22-23) One standard assessed was met Since the last inspection the home has received no complaints. The complaints procedure remains unchanged and is displayed. Environment (Standards 24-30) One standard assessed was met On the day of inspection the home was observed to be homely, comfortable, clean and odour free. Individual bedrooms for service users were personalised and individualised. Staffing (Standards 31-36) One out of three standards assessed were met Staffing levels at the care home remain appropriate for the numbers and needs of service users. The staff rosters continue to evidence that some staff are working long days/double shifts. No new staff have been recruited to the home since the last inspection. Not all records as required by regulation were available for inspection. Conduct and Management of the Home (Standards 37-43) One standard assessed was met The acting manager has vast experience working with adults/children who have a learning disability. The managers application to be formally registered with the Commission has been processed and a `Fit Person` interview undertaken. Luncies Road (97) Page 7 Requirements from last Inspection visit fully actioned? If No please list below NO STATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Regulation Standard Required actions Timescale for action Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). MET (YES/NO) Luncies Road (97) Page 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office. STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Regulation Standard * Requirement Timescale for action The registered person must ensure that at all times suitably, qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. This refers specifically to some staff working long hours/shifts. Ensure that all records as required by regulation are kept in the care home and available for inspection. This is a third repeat requirement The registered person must ensure that risk assessments for maintaining safe working practices within the home are not general and must be adapted to the home. Not inspected on this occasion Carried forward to next inspection 1 18(1)(a) OP33 01.08.05 2 17(2), Schedule 4 OP34 and 19(1), Schedule 2 01.08.05 3 13(4) YA42 Luncies Road (97) Page 9 RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Refer to Good Practice Recommendations Standard * 1 YA32 A minimum of 50 of staff obtain NVQ Level 2 by 2005. PART B INSPECTION METHODS & FINDINGS The following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling • Pre-inspection questionnaire • Records • Care plans / Care pathways • Meals • Activities • Other enter details here ‘Tracking’ care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: YES YES NA YES YES NO NO NA YES NO NO NO YES YES NO NO NO YES NO YES Luncies Road (97) Page 10 Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) X X X NA NA YES NA X X 09/03/05 08.40 4 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls) 0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. “X” is used where a percentage value or numerical value is not applicable. Luncies Road (97) Page 11 Choice of Home The intended outcomes for the following set of standards are: • • • • • Prospective service users have the information they need to make an informed choice about where to live. Prospective service users’ individual aspirations and needs are assessed. Prospective service users know that the home they 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. Standard 1 (1.1 – 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users’ guide. X X Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are Key findings/Evidence This standard was not assessed. Standard met? 0 Standard 2 (2.1 – 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 0 Key findings/Evidence Standard met? No new service users have been admitted to the care home. Luncies Road (97) Page 12 Standard 3 (3.1 - 3.10) The registered person can demonstrate the home’s capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? Since the last inspection, all but one member of staff has completed part one of the training course pertaining to ‘Positive Approaches to Supporting People with Autism”. One member of staff commented that they found the course useful. Epilepsy training for staff is planned for the foreseeable future. In addition, Abuse Awareness training is planned for those staff members who have not already received this. A training profile was available for mandatory training for 2005-2006. Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 0 Key findings/Evidence Standard met? This standard was not assessed Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 3 Key findings/Evidence Standard met? Individual service users’ contracts have been revised and reissued. Contracts were observed to be pictorial and use simple language. Luncies Road (97) Page 13 Individual Needs and Choices The intended outcomes for the following set of standards are: • • • • • 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. Standard 6 (6.1 – 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 3 Key findings/Evidence Standard met? On inspection of one service user care plan, this was noted to meet the required standard and contained detailed and informative information. Evidence indicated that the care plan had been reviewed since the last inspection. Standard 7 (7.1 – 7.7) Staff respect service users’ right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion. Luncies Road (97) Page 14 Standard 8 (8.1 – 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 3 Key findings/Evidence Standard met? Wherever possible, service users continue to be encouraged and empowered to participate within the running of the home. Standard 9 (9.1 – 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service user’s individual Plan and of the home’s risk assessment and risk management strategies. 3 Key findings/Evidence Standard met? Risk assessments were evident and these were seen to be comprehensive and detailed. Standard 10 (10.1 – 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the home’s written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion. Luncies Road (97) Page 15 Lifestyle The intended outcomes for the following set of standards are: • • • • • • • 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. Standard 11 (11.1 – 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 3 Key findings/Evidence Standard met? Staff within the home continue to encourage and empower service users to maintain and develop independent living skills. Standard 12 (12.1 – 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion. Luncies Road (97) Page 16 Standard 13 (13.1 – 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 3 Key findings/Evidence Standard met? Records continue to indicate that regular social/leisure activities are provided and undertaken by service users in the home and local community. Standard 14 (14.1 – 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. Key findings/Evidence Standard met? This standard was not assessed on this occasion. 0 Standard 15 (15.1 – 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? The home continues to operate an ‘open visiting’ policy whereby service users can receive visitors/friends at any reasonable time. Standard 16 (16.1 – 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion. Luncies Road (97) Page 17 Standard 17 (17.1 – 17.9) The registered person promotes service users’ health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Menus at the home are compiled weekly between staff and service users. Pictorial aids are available to enable service users to make a choice. Nutritional records evidenced that service users receive a varied range of meals suitable for their needs. Luncies Road (97) Page 18 Personal and Healthcare Support The intended outcomes for the following set of standards are: • • • • 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. Standard 18 (18.1 – 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users’ privacy, dignity, independence and control over their lives. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion. Standard 19 (19.1 – 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) 0 0 3 Key findings/Evidence Standard met? Evidence indicated that service users have access to a wide range of healthcare professionals and agencies. Luncies Road (97) Page 19 Standard 20 (20.1 – 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the home’s policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 3 Key findings/Evidence Standard met? The home medication records and storage facilities were seen to be satisfactory. All issues highlighted at the last inspection have been addressed. Standard 21 (21.1 – 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 3 Key findings/Evidence Standard met? From inspection of one care plan, information was available pertaining to the service users and/or their representatives wishes relating to funeral arrangements/terminal care. The Inspector was advised that bereavement counselling is available for both service users and staff. A policy was evident relating to ‘Death of a Resident/Service User’. Luncies Road (97) Page 20 Concerns, Complaints and Protection The intended outcomes for the following set of standards are: • • Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. Standard 22 (22.1 – 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 0 0 0 0 0 0 100 3 Key findings/Evidence Standard met? Since the last inspection, no complaints have been received at the home. Luncies Road (97) Page 21 Standard 23 (23.1 – 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists Key findings/Evidence This standard was not assessed on this occasion. YES 0 Standard met? 0 Luncies Road (97) Page 22 Environment The intended outcomes for the following set of standards are: • • • • • • • 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. Standard 24 (24.1 – 24.13) The home’s premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users’ individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? On the day of the inspection, the home was noted to be homely and comfortable for service users. In addition, the home was clean and odour free. No health and safety issues were highlighted at the time of the inspection Luncies Road (97) Page 23 Standard 25 (25.1 – 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) – single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite Key findings/Evidence This standard was not assessed on this occasion. YES NO NO X X X X Standard met? 0 X X X X X X Luncies Road (97) Page 24 Standard 26 (26.1 – 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. Key findings/Evidence This standard was not assessed on this occasion. Standard met? 0 Standard 27 (27.1 – 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion. Standard 28 (28.1 – 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion. Luncies Road (97) Page 25 Standard 29 ( 29.1 – 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the home’s stated purpose and the individually assessed needs of all service users. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion. Standard 30 (30.1 – 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion. Luncies Road (97) Page 26 Staffing The intended outcomes for the following set of standards are: • • • • • • 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. Standard 31 (31.1 – 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and other’s roles and responsibilities. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion. Standard 32 (32.1 – 32.6) Staff have the competencies and qualities required to meet service users’ needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion. Luncies Road (97) Page 27 Standard 33 (33.1 – 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users’ assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme X X X X X No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X X X X 2 Key findings/Evidence Standard met? On inspection of the home’s staff rosters, these indicated that appropriate staffing levels are being maintained for the numbers of service users residing at 97 Luncies Road. The rosters indicate that some members of staff are working long days/double shifts, i.e. 8:00 a.m.-9:00 p.m. (total 13 hours) and 7:30 a.m.-9.30 p.m. (total 14 hours). The Acting Manager was advised that this is not good practice and places both staff and service users at possible risk. Currently, there are staff vacancies for 2 x 20 hours night-time shifts and 1 x 18.5 hours daytime vacancy. Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 1 Key findings/Evidence Standard met? No new staff have been recruited to the home since the last inspection. Not all records as required by regulation are available for inspection. Luncies Road (97) Page 28 Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users’. 3 Key findings/Evidence Standard met? This standard has been addressed within Standard 3. Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. Key findings/Evidence Standard met? This standard was not assessed on this occasion. 0 Luncies Road (97) Page 29 Conduct and Management of the Home The intended outcomes for the following set of standards are: • • • • • • • 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. Standard 37 (37.1 – 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. X 3 Key findings/Evidence Standard met? The Manager’s application to be registered with the Commission is being processed at present. The Manager has vast experience working with children/adults who have a learning disability. In addition, evidence was available to indicate that the Manager undertakes training on a regular basis and has attended many training courses. Standard 38 (38.1 – 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion. Luncies Road (97) Page 30 Standard 39 (39.1 – 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion. Standards 40 (40.1 – 40.6) The home’s written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion. Standard 41 (41.1 – 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met ? This standard was not assessed on this occasion. Luncies Road (97) Page 31 Standard 42 (42.1 – 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion. Standard 43 (43.1 – 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 0 Key findings/Evidence Standard met ? This standard was not assessed on this occasion. Luncies Road (97) Page 32 PART C (where applicable) COMPLIANCE WITH CONDITIONS Condition Care Home Comments Compliance YES Condition Category of Registration Comments Learning Disability (5) Compliance YES Condition Comments Compliance Condition Comments Compliance Lead Inspector Second Inspector Regulation Manager Date Michelle Love N/A Signature Signature Signature Luncies Road (97) Page 33 Public reports It should be noted that all CSCI inspection reports are public documents. Luncies Road (97) Page 34 PART D PROVIDER’S RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTS D.1 Registered Person’s comments/confirmation relating to the content and accuracy of the report for the above inspection. We would welcome comments on the content of this report relating to the Inspection conducted on 9th March 2005 and any factual inaccuracies: Please limit your comments to one side of A4 if possible Luncies Road (97) Page 35 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NO Comments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurate NO NO NO Note: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 12th July 2005, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. Luncies Road (97) Page 36 You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Provider’s Action Plan at time of publication of the final inspection report: Action plan was required YES Action plan was received at the point of publication NO Action plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action plan NO NO NO Other: enter details here NO Luncies Road (97) Page 37 D.3 PROVIDER’S AGREEMENT Registered Person’s statement of agreement/comments: Please complete the relevant section that applies. D.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons: Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable. Luncies Road (97) Page 38 Luncies Road (97) / 9th March 2005 Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.uk S0000018030.V214677.R01 © This report may only be used in its entirety. Extracts may not be used or reproduced without the express permission of the Commission for Social Care Inspection The paper used in this document is supplied from a sustainable source - 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!