Inspection on 24/04/07 for Elland Road

This inspection was carried out on 24th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Elland Road 20/04/09

Elland Road 09/02/06

Elland Road 26/07/05

Elland Road 30/12/04

Elland Road 15/06/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Snydale Care Home

Whitwood House

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

CARE HOME ADULTS 18-65 Elland Road 67 Elland Road Churwell Leeds West Yorkshire LS27 7QS Lead Inspector Carol Haj-Najafi Key Unannounced Inspection 24th April 2007 09:30 Elland Road DS0000001447.V330792.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 Elland Road DS0000001447.V330792.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. Elland Road DS0000001447.V330792.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elland Road Address 67 Elland Road Churwell Leeds West Yorkshire LS27 7QS 0113 2526561 0113 2526561 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) Northern Life Care Limited T/A U.B.U. Judith Wilson Care Home 7 Category(ies) of Learning disability (7), Physical disability (7) registration, with number of places Elland Road DS0000001447.V330792.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th February 2006 Brief Description of the Service: Elland Road is in Churwell near Morley, Leeds. It is on a main bus route and has good access to local shops, including the White Rose centre and Morley shopping centre. The home provides 24 hour care to seven younger adults with a learning disability, some of whom also have a physical disability. The home has a dining room and two lounges, one lounge is spacious and used regularly and the other is a smaller quiet area. The kitchen is domestic in character although access for people who use the service is limited. Six bedrooms have en-suite and are on the ground floor, one bedroom is on the first floor with easy access to a bathroom and toilet. There are three bathrooms, two which have assisted baths. The weekly charge is between £1,071 and £1,312. Elland Road DS0000001447.V330792.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk. The last key inspection was carried out in February 2006. A pre-inspection questionnaire was completed by the home and this information was used as part of the inspection process. Surveys were sent to relatives, and healthcare professionals, it was agreed with the manager that only one person who uses the service would be able to complete a survey and they would need support, therefore only one survey was sent out to people who use the service; responses from the surveys have been included in the inspection report. One inspector carried out a site visit which started at 9.30am and finished at 5.00pm. Feedback was given to the manager at the end of the visit. During the visit the inspector looked around the home, observed interaction between staff and people who use the service, spoke to a relative, staff and the manager. Discussions with people who use the service were only very brief. Care plans, risk assessments, healthcare records, meeting minutes, and staff recruitment and training records were looked at. What the service does well: Staff have very good knowledge about people who use the service and their individual care needs. They were able to provide very specific details about how they looked after them. Everyone works very hard to provide person centred care and to support people to achieve their ambitions, which helps maintain and develop skills. Surveys from relatives and healthcare professionals were positive and the following are a sample of responses and comments: • • • • • The care home helps their relative keep in touch The home provides a clean, caring and secure environment We are very satisfied with the care A great deal of thought goes into planning holidays so that people’s individual needs are met. Individuals’ privacy and dignity are always respected DS0000001447.V330792.R01.S.doc Version 5.2 Page 6 Elland Road • • • • • • • The service always supports individuals to live the life they choose The service always responds differently to the different needs of individuals The staff have always been helpful and willing to do their best The staff are very caring and nothing is too much trouble for them. Staff are excellent It is a well run and friendly place We know who to talk to if we are not happy about the service. People who use the service go out very frequently and have opportunities to experience a good range of activities. This includes swimming, local pubs and restaurants, train rides, bus journeys, shopping, hydrotherapy, reflexology, foot and hand massage, arts and crafts, sensory sessions, and listening to music. People who use the service are comfortable in their surroundings and have specialist equipment to help maximise their independence. The manager has good leadership skills and promotes a high standard of care. What has improved since the last inspection? What they could do better: Service user plans had been regularly reviewed but there had not been any changes to any of the plans in over twelve months, which suggests the reviews are not always completed properly. Staff talked about changes in care needs but this information had not been recorded at the reviews. Every person had new keyworker, preparing for a holiday and consultation plans but these were all identical, which demonstrates that they were not written specifically for the person. Some people pay for transport but there are no records of how their money is spent or details of who has used the vehicle. This system must be looked at to make sure payments are fair and they are getting value for money. Weight records were not up to date. The last recorded weight record was July 2005. The manager agreed to include a section in the healthcare file. Elland Road DS0000001447.V330792.R01.S.doc Version 5.2 Page 7 There are times when staffing levels are inadequate and this has affected the quality of the service. Good systems are in place to measure the overall quality of the service but it is difficult to monitor, over a period of time, the quality of care that each person has received because daily records are held on the computer and it is very difficult to retrieve information. The manager and staff acknowledged that monitoring was very difficult. Comment was made that they tend to put more information in the communication book and rely on handovers because looking through records is very time consuming. 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. Elland Road DS0000001447.V330792.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 Elland Road DS0000001447.V330792.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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Previous inspections and procedures indicate that a thorough admission process is carried out before people are admitted to the service, making sure their needs are met. EVIDENCE: The home’s Statement of Purpose was reviewed in January 2007; details of the changes were sent to the Commission at the time of the review. The people have lived at the home for at least two years so there was very little recent evidence for many aspects of this outcome group. The admission process was looked at during previous inspections and the relevant National Minimum Standards were exceeded. Each person who uses the service has been given an agreement that sets out the home’s terms and conditions, which includes the fees charged for their placement. Elland Road DS0000001447.V330792.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Everyone works very hard to provide person centred care and to support people to achieve their ambitions, which helps maintain and develop skills. EVIDENCE: Three people’s care records were looked at. There were several different documents that provide information about care needs. Documents describe what people like and dislike, how their needs should be met and potential risks. For example, one plan for the use of a telephone stated when someone picks up the telephone explain who you are and that I would like to speak to them, the plan also covered privacy. Another plan stated ‘I do not like my teeth being brushed with cold water’. Other plans gave details how to support people with communication aids and personal equipment. Each person had a plan that identified how they should be supported with their spiritual needs. Elland Road DS0000001447.V330792.R01.S.doc Version 5.2 Page 11 Staff had very good knowledge about people who use the service and their individual care needs. They were able to provide very specific details about how they looked after them. These were generally consistent with what had been recorded in care plans and assessments. Staff talked about some changes in care needs but care plans had not been updated and new plans had not been written. Plans were all originally written in January 2006, and each person had over sixty different identified care needs. The plans had been signed to say they had been regularly reviewed but in over sixteen months there had been no changes to any of the plans. Five new plans were introduced for each person in July 2006, these included choosing a keyworker, preparing for holiday, and consultation and participation. The plans were identical for everyone and at no stage did they cover involving relatives, which is a fundamental principle the home always follows. All staff and the manager talked about ‘targeted ambitions’. These are identified goals that have been agreed with all key people. Staff were familiar with each person’s individual ambitions and they gave examples of how they had supported people to achieve their ambitions. Elland Road DS0000001447.V330792.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15 & 16 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People who use the service have a good and fulfilling lifestyle but because the records are difficult to access a lot of the good work that is done is not easy to evidence. EVIDENCE: Four relative surveys were returned, these were positive about the standard of care that is provided and the following are a sample of responses and comments: • They are always kept up to date with important issues • The care home helps their relative keep in touch • The care service meets the different needs of people • The home provides a clean, caring and secure environment • We are very satisfied with the care Elland Road DS0000001447.V330792.R01.S.doc Version 5.2 Page 13 • A great deal of thought goes into planning holidays so that their individual needs are met. A relative, who regularly visits the home, said the person who uses the service was very well cared for, the staff were very good and they were always made to feel very welcome. Staff said the home provided a good service and they thought people who use the service had a good lifestyle. They said people go out very frequently and have opportunities to experience a good range of activities. This included swimming, theatre, church, local pubs and restaurants, cinema, bike riding for disabled, train rides, bus journeys, shopping, hydrotherapy, reflexology, foot and hand massage, physiotherapy, arts and crafts, baking, gardening, sensory sessions, and listening to music. Financial records provided evidence that people went out frequently and had engaged in varied activities. Daily records are held on the computer and staff make entries at least three times a day. They record important information about each person, and this includes what they have been doing, what they have eaten and any healthcare appointments. As part of the inspection process, a few weeks of daily records should be looked at. It was not possible to do this in the time allocated because each entry has to be looked at individually and after viewing each entry the computer goes back to main menu. Four weeks of daily records would contain at least 112 different entries. This system is not effective because staff and the manager cannot properly monitor events. The manager and staff acknowledged that monitoring was very difficult and even though staff should look at all relevant records when they come on shift, it is not possible because three or four staff would have to look through seven people’s records. Comment was made that they tend to put more information in the communication book and rely on handovers. The home has a minibus that people use. Everyone pays £22 per week towards the cost of the vehicle. Transport records identified how often the vehicle was used but not the people that have travelled in the vehicle, therefore it is not possible to monitor if they are getting an equitable service or value for money. Some people have paid for taxis because they could not use the vehicle; occasionally this has been because a driver was not available. The registered provider must be able to account for mobility payments and demonstrate that people are getting value for money and an equitable service. Menus were sent with pre inspection questionnaire; these were varied and nutritious. Staff said they are responsible for devising weekly menus, which are based on people’s preferences. There will often be variations to the menu and these are recorded on people’s daily records. On the day of the inspection, bacon and tomatoes were on the menu; meals provided were bacon and tomato, chicken bites, fish pie, and haddock, mash and green beans. Again, it Elland Road DS0000001447.V330792.R01.S.doc Version 5.2 Page 14 would be very difficult to monitor nutrition if people regularly eat variations to the menu. Elland Road DS0000001447.V330792.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. We have made this judgement using a range of evidence, including a visit to the service. Personal support is based on the preferences of people who use the service and expert knowledge. Although there was evidence that people were receiving the right support from healthcare professionals, the system to monitor healthcare needs should improve to make sure all healthcare needs are met. EVIDENCE: Staff talked about the work they had done to improve communication for people who use the service. They had explored different communication methods with other professionals and through the goal setting process, which is called ‘targeted ambitions’ they have introduced better communication systems. For example one person has a communication board, and the person uses this to tell staff what they would like to do. Two healthcare surveys were returned. The surveys were positive and the following responses and comments were included: Elland Road DS0000001447.V330792.R01.S.doc Version 5.2 Page 16 • • • • Individuals’ privacy and dignity are always respected The service always supports individuals to live the life they choose The service always responds differently to the different needs of individuals The staff have always been helpful and willing to do their best Staff said they thought the home was good at consulting healthcare professionals when they want advice and support. They gave examples when they had involved various healthcare professionals. The manager had identified that the system they had for recording and monitoring healthcare was not effective because it was difficult to find out when people had attended past appointments. As a result of this, a new system was being introduced, and each person had a healthcare file. It was in the early stages and some information was still not available. Because this shortfall was being addressed it has not been necessary to make a requirement specifically about healthcare but a general requirement about recording and monitoring has been made. Weight records were not up to date. The last recorded weight record was July 2005. The manager agreed to include a section in the healthcare file. The administration of medication was observed and this was administered appropriately. Medication and medication records were looked at and the amount of medication and the records corresponded. Medication storage was looked at and the medication was well organised. Elland Road DS0000001447.V330792.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 the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Satisfactory procedures are in place and people will report their concerns, therefore people who use the service are protected. EVIDENCE: Surveys stated they know how to make a complaint and if they have raised concerns the response has been appropriate. A relative, who regularly visits the home, said they discuss any concerns with the manager who always wants to make things work. The home has not received any complaints within the last twelve months. The manager and staff have attended adult protection training and they were familiar with the adult protection procedures. Personal allowance records were looked at. All financial transactions were recorded and receipts were obtained for any purchases made. Two people’s monies were counted and the amount corresponded with the amount on the balance sheet. A financial transaction record sheet was not found for one person, therefore it was not possible to look at the transactions between 31/01/07 and 19/04/07. Staff said the record had been in the file at the weekend and they believed it had been put in the wrong place. The manager Elland Road DS0000001447.V330792.R01.S.doc Version 5.2 Page 18 said this was very unusual and staff had been asked to go through other records. Elland Road DS0000001447.V330792.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, 26, 27, 28, 29 & 30 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People who use the service are comfortable in their surroundings and have specialist equipment to maximise their independence. EVIDENCE: A tour of the building was carried out. Communal areas, bathrooms and bedrooms were visited. The home was clean and tidy and generally there were no odours. People who use the service walked freely around the home and used all communal areas. Bedrooms were very personal, and careful consideration has been given to the décor to ensure it reflects the preferences of the people who live there. Each room had photographs, pictures and personal items. A lot of different equipment was available to help maintain skills and promote independence. Elland Road DS0000001447.V330792.R01.S.doc Version 5.2 Page 20 The furnishings, carpets, and furniture are good quality and the home is decorated to a high standard. There were some minor maintenance and decoration problems noted during the tour of the building. • • • The en-suite flooring in one room was damaged. One bedroom had been decorated several months ago but it was not finished because the wallpaper border had not been put on. There was a slight odour in one bedroom. Staff said the room was cold in winter and hot in summer. The manager said generally repairs and maintenance problems were dealt with promptly and agreed to organise work to address the maintenance problems identified at the inspection. The call bell system was activated at several points. It was not possible to hear the call bell in certain parts of the home. It is important to make sure people who use the service and staff can contact others in an emergency, and any equipment is fit for purpose. Elland Road DS0000001447.V330792.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 & 36 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The staff team work well together and everyone works hard to provide good individual care. Staff feel well supported and systems are in place to make sure everyone has an opportunity to develop. There are times when staffing levels are inadequate and this has affected the quality of the service. EVIDENCE: Surveys stated: • The staff are very caring and nothing is too much trouble for them. • Staff are excellent • It is a well run and friendly place • Staff have the right skills and experience • Sometimes new staff can take time to adjust Staff said the team works well together and communication was good. They have a daily handover where information is passed on to staff who are starting their shift. Elland Road DS0000001447.V330792.R01.S.doc Version 5.2 Page 22 Staff meetings are held every month. Staff said these were good opportunities to discuss anything that was relevant to the home. The minutes from the meetings were detailed and a good source of information for staff who were not present. Staff also said they received regular supervision and had opportunities for personal development. Staff said staffing levels were sometimes a problem, and on occasions there were only two staff working on shift, which does not provide opportunities to take people out or spend quality time with people. There should be at least three staff working on each shift during the day. Four weeks of staff rotas were sent with the pre inspection questionnaire and only two staff were working for three shifts during that period. Records identified that the day before the inspection, one person could not attend their dentist appointment, and two days before the inspection people could not have their Sunday lunch at lunchtime and had it in the evening. The changes were because there were not enough staff on shift. Concerns were raised that it was difficult when only two staff were on shift, and although it did not happen on a frequent basis, it had caused problems recently. The manager said there had been a problem recruiting staff because there was a shortage of suitable applicants. A recruitment road show was being arranged for May. One staff member talked about the recruitment process and confirmed they had completed all the relevant information before they commenced employment. They also said they had completed a good induction programme when they started. Recruitment records for three staff were looked at. All the relevant information was available. Staff said they had opportunities to attend a good range of training courses. Training records were looked at. Staff had attended various training courses including, person centred planning, health and safety, adult protection, complex behaviour, epilepsy and working safely. Seven staff had completed NVQ level 2 or above, one had almost finished and five were in the process of completing it. The manager had identified that some staff had not updated their training and had produced a training plan. Food hygiene was seen as the priority. Because this shortfall was being addressed it has not been necessary to make a requirement to meet the Care Homes Regulations. Elland Road DS0000001447.V330792.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41 & 42 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The manager has good leadership skills and promotes a high standard of care. Good systems are in place to measure the overall quality of the service but it is difficult to monitor, over a period of time, the quality of care that each person has received. EVIDENCE: The manager is a registered nurse and has completed NVQ management level 4. Relatives and staff were very complimentary about the manager and they thought the home was well managed. Staff said she is supportive, makes sure everything gets done and puts people who use the service first. Elland Road DS0000001447.V330792.R01.S.doc Version 5.2 Page 24 Once a month the area manager visits the home and looks at the general conduct, these visits are called Regulation 26 visits. A copy of the Regulation 26 report is sent to the Commission. Surveys are sent out to relatives annually. They were last sent out in January and the manager was waiting for the results. Accident and incident records were looked at. All relevant information was recorded. As stated previously in the report there were some problems with the recording system because it was difficult to evidence some of the good work done with people who use the service and it was difficult to monitor how health and welfare needs were being met. The pre inspection questionnaire stated that policies and procedures were available and regular maintenance and health and safety checks by external agencies were completed at the home. The organisation’s accounts were reviewed by the Commission’s finance department and on the basis of the information available UBU is regarded as being financially viable. Elland Road DS0000001447.V330792.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 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 4 27 4 28 4 29 2 30 3 STAFFING Standard No Score 31 3 32 3 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 2 14 4 15 4 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 2 3 X 3 4 3 3 2 3 3 Elland Road DS0000001447.V330792.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 YA6 Regulation 15 Requirement It is important to make sure service user plans are properly reviewed and kept up to date, and any new plans are individualised The registered provider must review the transport arrangements to make sure charges to people who use the service are recorded, equitable and value for money. It is important to make sure people who use the service are weighed regularly as part of the healthcare monitoring system. The registered provider must ensure the call bell system is appropriate for the purpose Staffing levels must be closely monitored to make sure there are sufficient staff on duty to meet the needs of the people who use the service. Information about people who use the service must be in a format that enables their health and welfare to be properly monitored. Timescale for action 31/05/07 2. YA13 17 12 16 30/06/07 3. YA19 12 31/05/07 4. 5. YA29 YA33 23 18 31/08/07 31/05/07 6. YA41 12 30/06/07 Elland Road DS0000001447.V330792.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Elland Road DS0000001447.V330792.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Elland Road DS0000001447.V330792.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!