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Inspection on 27/08/08 for Boldshaves Oast

Also see our care home review for Boldshaves Oast for more information

This inspection was carried out on 27th August 2008.

CSCI found this care home to be providing an Good service.

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.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Boldshaves Oast Frogs Lane Woodchurch Ashford Kent TN26 3RA The quality rating for this care home is: two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Wendy Gabriel Date: 2 7 0 8 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area Outcome area (for example: Choice of home) These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Reader Information Document Purpose Author Inspection report CSCI Page 2 of 31 Care Homes for Adults (18-65 years) Audience Further copies from Copyright General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 31 Information about the care home Name of care home: Address: Boldshaves Oast Frogs Lane Woodchurch Ashford Kent TN26 3RA 01233860039 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): leotrust@btconnect.com The Leo Trust Name of registered manager (if applicable) Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 15 Number of places (if applicable): Under 65 Over 65 15 0 Learning disability Additional conditions: The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability (LD) The maximum number of service users to be accommodated is 15 Date of last inspection Care Homes for Adults (18-65 years) Page 4 of 31 A bit about the care home Boldshaves Oast is registered to provide accommodation for up to 14 adults with a learning disability. Two of which are accommodated in a self-contained cottage in the grounds with some staff support. Another two are accommodated in a purpose built log cabin in the grounds with staff support. The company The Leo Trust owns the business. The Chief Executive Officer Mr Joe Graham has day-to-day responsibility for the Home and also manages another coowned home nearby. The main premise is a converted Oast with accommodation on three floors. All bedrooms in the main Oast are singles. Five rooms have ensuite facilities. The other four residents either have the sole use of a bathroom or share with one other. There is a kitchen, dining room and two lounges. All rooms have extensive views over the countryside. There is a deckling and porch area from the main Oast, which is surrounded by a large well-maintained garden with large duck ponds, and horticulture project with Poly-tunnels, further paddock and car parking space. The home is situated down a drive from a quiet country lane. In a remote rural position, one and a half miles from the village of Woodchurch and four and a half miles from Tenterden. Within the village of Woodchurch there is the local GPs surgery, post office, church and two pubs, the home has transport, which can be used for residents if they wish. The current fees are in the range of £572.68 -£1889.24. Care Homes for Adults (18-65 years) Page 5 of 31 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home Care Homes for Adults (18-65 years) Page 6 of 31 How we did our inspection: This is what the inspector did when they were at the care home Key Lines of Regulatory Assessment (KLORA) have informed the judgements made based on records viewed, observations made and written and verbal responses received. KLORA are guidelines that enable the Commission for Social Care Inspection (CSCI) to make an informed decision about each outcome area. The information for this report has been gained from an Annual Quality Assurance Assessment (AQAA) completed by the service; comment cards completed by 4 staff and 6 residents; notifications of significant events submitted by the home since the last inspection; and a site visit to the service by two inspectors that lasted 5 1/2 hours. The site visit was unannounced. This means that neither the staff nor the residents knew that we (the Commission) were going to visit. During the site visit we spoke with the majority of the residents, staff on duty, the Chief Executive Officer, deputy manager and Finance Director. Observations were made of residents enjoying their normal daily life, and the way in which the staff interacted with them. Page 7 of 31 Care Homes for Adults (18-65 years) We had a tour of the premises and observed its cleanliness, maintenance, and infection control procedures. We looked at medication including administration, policies, storage, and records. A variety of other records were in inspected including care plans, complaints information, records of monies handled for residents, staff recruitment files, rotas, and training records, quality assurance records, and some health and safety records. The registered manager for this home left the service in January 2008. The provider has appointed someone else to manage the service, Michelle Chorlton, but she has not yet applied to the Commission to become the Registered Manager. This person will be referred to as the manager throughout the report. A caution was served on the service in January 2008 for breach of conditions of registration (over numbers) under Section 24 of the Care Standards Act 2000. An application to increase the number to 14 was granted. The service was seen during this inspection to meet its conditions of registration. The planning application has since been successful. Care Homes for Adults (18-65 years) Page 8 of 31 What the care home does well There is a good assessment and introduction system in place for prospective residents. Residents are enabled to enjoy a wide range of culturally and age appropriate interests. Married couples are supported to live independent lifestyles, with their own dedicated accommodation. Residents health care needs are assessed and met with community support The home is well maintained and located in a very pleasant setting. There is a stable and caring staff team to look after the residents. There is a positive management approach and good leadership of the service. A resident comment card included that he is very happy in this beautiful house and that he is very happy here. A staff comment card stated, The service provides a friendly homely environment for our residents. Residents are supported with tasks in their everyday life and efforts are made to facilitate any special things they may want to do. Residents are treated as individuals with individual needs. Care Homes for Adults (18-65 years) Page 9 of 31 Relative comment The quality of service is excellent in every way. What has got better from the last inspection What the care home could do better New staff should have induction that complies with current recommendations and staff training needs to be kept up to date. The new manager must apply to the Commission to become the Registered Manager Care Homes for Adults (18-65 years) Page 10 of 31 If you want to read the full report of our inspection please ask the person in charge of the care home If you want to speak to the inspector please contact Wendy Gabriel 33 Greycoat Street London SW1P 2QF 02079792000 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line - 0870 240 7535 Care Homes for Adults (18-65 years) Page 11 of 31 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 12 of 31 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Prospective residents have information to make an informed choice about where to live. Prospective residents know their needs and choices will be assessed and that they have the opportunity to visit the home Evidence: The manager will visit a prospective resident to make an assessment and this will include assessments from the care manager and health care professionals as necessary. Visits including overnight stays are made by the prospective resident to enable an informed choice to be made about living at the home. A six-month trial period will begin and a final assessment including the care managers review will determine if the resident is happy and that his or her needs are able to be accommodated by the service. A written comment received from one resident says I do like living here in Leo trust and part of my life, when I get older till end of my life. Another comment (written by staff on behalf of resident ) says that the resident first visited and was told all about the home. Then the resident came for a second visit and decided he really liked it. Care Homes for Adults (18-65 years) Page 13 of 31 Evidence: There is a statement of purpose and service user guide. The manager is currently reviewing and updating these and she explained that she is going to make them person centred and the new form will be in simple print and picture format. Contracts are also in place and the manager said she is also reviewing these and getting residents to sign them. Some were seen in picture and print format. Married couples living at the service have additions to their contracts detailing terms and conditions about their particular living situation regarding accommodation. The manager agreed to make sure each married resident has their contract on their file. Care Homes for Adults (18-65 years) Page 14 of 31 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Residents know their care plans reflect their needs and aspirations and that they are reviewed. Residents are assisted and encouraged to make decisions about their lives. Risk assessments enable residents to take risks as part of their lifestyle. Evidence: The manager has worked hard since coming into post in January to methodically review and update all of the care plans. Staff have updated the assessments. There was evidence of reviews by the home and by care management as well as some information, as appropriate, from health care professionals. The manager is starting to make the care plans person centred and is using picture and print towards this end. The manager has made residents strengths an important part of the plan and intends to improve on this. Residents are also being encouraged to sign their own documents that detail issues such as likes and dislikes and choices. A written comment received from a member of staff stated that Information is always passed over at handover or a note is put in the communication book to read the changes in the care plan. Residents have weekly meetings. Risk assessments although in place, are also being Care Homes for Adults (18-65 years) Page 15 of 31 Evidence: updated into a different format that the manager hopes will benefit staff by being clearer to read and understand. The manager is putting more guidance for staff into the documents. Care Homes for Adults (18-65 years) Page 16 of 31 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Residents have excellent opportunities for personal development and to take part in age, peer and culturally appropriate activities. Residents enjoy a wide range of activities in the home and in the community. Residents are supported to have appropriate relationships. Menues are varied and meet dietary needs or choices. Evidence: Residents are enabled to enjoy a wide range of culturally and age appropriate interests. These are indicated on individual picture and print activity charts. Two residents go to work. One works at a local supermarket and the other at a family run toy business. When one resident returned from work she said, It was very busy at work today. I do packing at (the supermarket). Although many residents thoroughly enjoyed attending college, recent initiatives mean that the college they attended has now chosen to run courses mainly for people in independent living schemes. This is a great shame and a blow to the residents at Care Homes for Adults (18-65 years) Page 17 of 31 Evidence: Boldshaves. The manager is trying to access other training courses to meet the choices of the residents. But as she explained, part of the enjoyment of attending college was mixing with others from a different environment. One person showed us his college certificates and said he liked going to college very much and joked about the different things he could now do because of his different courses. Staff comments about activities included, Residents have loads of trips out, Sometimes they almost have too much choice of activity, Activities include Fitness and dancing sessions three times a week, and horse riding, and Holidays have included Bognor Regis, Hastings, and Dymchurch. Staff also commented, Residents get more choices than we do, Choices include meals, what they do, when they get up …, and at Weekends they can relax more.Three residents were on holiday with their families at the time of the site visit. One resident said he was working in the grounds that day in the horticultural project that has a dedicated support worker/trainer. A woodwork workshop is also in the grounds and plans are for residents to display and sell products at a County event next year. Two residents go to church weekly. Many events are undertaken in the community and the service has events in the grounds including concerts and fetes. Two married couples had their weddings supported by the home and staff and one man happily showed his wedding photographs and talked about the big day. Both couples have their own homes within the grounds and these are very well furnished and equipped and personal to each couple. One woman also talked enthusiastically about her wedding. One person was in his home and being supported at the time by a support worker. Cooking was being undertaken for their dinner and the support worker and he confirmed that they tried different recipes all the time. Residents in one cottage write their choice for the week and then the appropriate food is purchased for them. Residents receive a nutritious, varied and balanced diet. The residents grow much of the vegetables and fruit during their Horticultural sessions. Residents also help the staff with meal preparation when they wish. One resident had made some raspberry buns on the day of the site visit and was sharing these with his colleagues. Meal times are flexible and residents were witnessed taking advantage of being able to eat at the time suitable for them. The main dining area is spacious; however residents may eat in their own rooms if they wish. Special diets are catered for as needed. Comments from relatives on the homes own quality assurance questionnaires included, Always a well balanced diet with good variety, I think the dining room addition is wonderful, and The meals I have seen being prepared look fantastic. Staff said, Residents have very good home cooked food, and The residents choose the menus. Care Homes for Adults (18-65 years) Page 18 of 31 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Residents know that the personal support they receive will be in a way that suits them and that their physical and emotional health needs are assessed and met. Evidence: Residents receive support in the way they prefer. Care plans record personal likes and dislikes and what staff should do to support people. Risk assessments identify particular physical and emotional needs for staff to be aware of. Although there is some detail in the risk assessments the manager agreed to add further guidance for example to include what staff should be aware of in different environments as well as within the home. The homes policies and procedures for the receipt, storage, administration, and disposal of medication are sound. All staff who administer medication have received appropriate training. The homes AQAA tells us that there have been a number of improvements to medication practices during the past year including, We have changed the pharmacy who supplies our medication. We have purchased a new medication trolley. We have also purchased a lockable fridge for the storage of temperature controlled medication. We have implemented a medication audit where the medication is counted and recorded three times a day. The new pharmacy deliver Care Homes for Adults (18-65 years) Page 19 of 31 Evidence: to and collect from the home. Care Homes for Adults (18-65 years) Page 20 of 31 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Residents are able to express their concerns, and have access to a robust, effective complaints procedure. Residents are protected from abuse. Evidence: Residents are protected from abuse, neglect and self-harm. The home has robust policies for the protection of vulnerable adults. There have been no incidents of abuse and no safeguarding referrals since the last inspection. No new member of staff is employed in the home until a satisfactory check of the Protection of Vulnerable Adults register has been received. Staff spoken to on the day of the site visit confirmed that they understand the abuse and whistleblowing policies. The home has a clear and accessible complaints policy. A copy of the residents grievance procedure is on display in the hallway. The homes AQAA indicates an improvement made in the last 12 months to be A complaint form in picture and print format has been implemented to make it easier for residents to express any complaints in a formal way. There have been no complaints made since the last inspection. Comments from relatives on the homes own quality assurance questionnaires included, I know how to complain should it be necessary, all comments are listened to with understanding and sympathy and acted upon quickly, and Residents are treated as adults. All residents finances are dealt with appropriately. Monies are checked daily and audited weekly. Care Homes for Adults (18-65 years) Page 21 of 31 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . The physical design and layout of the home enables residents to live in a safe, wellmaintained and comfortable environment, which encourages independence. Evidence: All bedrooms are single. Many of the bedrooms are fitted with en-suite facilities. There are also ample toilet and bathing facilities for communal use. Other residents share bathrooms or shower rooms. Bedrooms are highly individual in size, shape and content. One resident enjoyed showing us his room and said he had chosen it not long ago and loved the room. He also showed us the adjoining bathroom and that he loved that too. Residents are able to have a key to their door and to lock it when they wish or if they require privacy. One resident said, Ive got a key for the front door. The large lounge is comfortably furnished and spacious and the quiet lounge, dining room and dining room extension are attractively furnished and light and airy. The kitchen is in part of the roundel and has been fitted to reflect the shape. Lunchtime was busy in the kitchen and dining room areas and was a happy and lively environment. The home is clean and is kept hygienic and free from offensive odours throughout. Sufficient systems are in place to control the spread of infection. The laundry is located in one of the outbuildings and contains equipment with the correct programming ability to meet disinfection standards. A cottage in the grounds and a cabin, near the main house are homes to the two Care Homes for Adults (18-65 years) Page 22 of 31 Evidence: married couples. Both are furnished in an attractive and homely manner and include kitchen, dining area, lounge, bedroom and bath or shower room. A second cabin in the grounds is used for two residents and as a sleep in room for staff. Both residents rooms can access the outside including a secure garden area for one person. This cabin is currently the subject of planning application. This will be reviewed on the resolution of the planning application currently with Ashford Borough Council. A caution was served in January 2008 for breach of conditions of registration (over numbers) Section 24 of the Care Standards Act 2000. An application to increase the number to 14 was granted. The service was seen during this inspection to meet its conditions of registration. The planning application has since been satisfactorily resolved. Care Homes for Adults (18-65 years) Page 23 of 31 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Staff in the home are skilled and in sufficient numbers to support the residents. Additional training will further support and protect the residents Evidence: Staff teams have been reorganised to ensure each resident has a key worker available on each day shift. The AQAA states that : We follow our recruitment procedure ensuring that all potential staff have the correct CRB checks in place before starting work. Significant numbers of staff are trained to NVQ level 2 or above and any new starters are encouraged to do so. We also provide the opportunity for all necessary training needs including any not classified as mandatory. We have an on going training log to ensure that all training is carried out and update as required.Staff receive regular supervisions to provide the confidential opportunity to discuss and issues or concerns, their progress and any training needs. All staff also attend a yearly appraisal. Staff working at the home have the qualities required to meet the residents needs. Currently 55 of staff are trained to NVQ 2 or above and more staff are undertaking this training. There is a stable and committed staff team working at the home. Staff confirmed that there are always sufficient staff on duty to meet the needs of the residents, and commented, Absolutely, and Sometimes too many. Care Homes for Adults (18-65 years) Page 24 of 31 Evidence: Comments from relatives on the homes Quality Assurance questionnaires included, Well trained and caring staff who are always willing to do that bit extra when required, Staff members and management are always available should it be required, I think all staff bar none are wonderful people and very caring, and I am always impressed by the quality of carers you recruit and the fact that so many of them stay for so long. That is a very good sign and gives one confidence to entrust the life and welfare of our children with you. The home has sound recruitment procedures. All staff have a copy of their statement of terms and conditions of employment. The new manager is working hard to try to get staff training up to date as this had been let slip. A requirement has been made regarding this. A variety of DVD training packages have been purchased and the manager and the finance director are both trainers for these packages. The homes AQAA says, We have introduced a training log to enable easier identification of training needs to help improve the staff personal development needs. General comments from staff included, Its good team work here, It feels different from other places, We support each other, and A lot of staff travel quite a way because they like to work here. Care Homes for Adults (18-65 years) Page 25 of 31 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . The management and administration of the home is based on openness and respect and has effective quality assurance systems. The health, safety and welfare of residents and staff is protected Evidence: The last registered manager for the home left the service at the end of January this year. A new manager, Michelle Chorlton, has been appointed by the provider to run the home but has not yet submitted an application to become the Registered Manager. A requirement is made regarding this. The manager has had to undertake some detailed work regarding care plans and assessments to meet requirements made at the previous inspection. These have been tackled robustly. Good progress has been achieved and plans are now being made person centred. Some work is still to be completed but the manager has a very clear view of her responsibilities and of the way she wants the service to progress. Staff confirmed that the manager is supportive and stated, Excellent support. She is always at the end of the phone if she is not here, and She is much better than the last manager, communication is much better. Care Homes for Adults (18-65 years) Page 26 of 31 Evidence: The home has developed its own quality assurance systems. Quality questionnaires are circulated to relatives of all residents and the results of these surveys are analysed and acted upon. Comments on the surveys included, A very big thank you to you all for doing such a wonderful job, My family and I are very happy with the Leo Trust, I am extremely happy with the service that my brother receives, and I think the home is a truly wonderful place for my son. Regular audits that are undertaken include Medication, residents monies, health and safety, and maintenance. The home has qualified for Investors in People accreditation. The health, safety and welfare of residents and staff is promoted and protected by the home. However, there are currently some gaps in the mandatory health and safety training and a requirement has been made about this in the staffing outcome area. All health and safety records examined on the day of the site visit were up to date and relevant. Care Homes for Adults (18-65 years) Page 27 of 31 Are there any outstanding requirements from the last inspection? Yes  No  Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No Standard Regulation Requirement Timescale for action 1 35 18 & schedule Up date staff training 31/12/2006 2 records, complete an audit of training and produce a plan to address any shortfalls Care Homes for Adults (18-65 years) Page 28 of 31 Requirements and recommendations from this inspection Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No Standard Regulation Description Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set No Standard Regulation Description Timescale for action 1 35 18 31/12/2008 All new staff must receive induction which complies with Skills for Care recommendations; and all staff must be trained and kept up to date in the mandatory health and safety related subjects and POVA. Currently not all staff are up to date with mandatory training and this could put residents at risk. 2 37 8 An application for registration must be submitted within three months in respect of the current manager. 30/11/2008 A person who manges a home must be registered by CSCI. Recommendations Care Homes for Adults (18-65 years) Page 29 of 31 These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Adults (18-65 years) Page 30 of 31 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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