Inspection on 23/06/05 for L and S Care

This inspection was carried out on 23rd June 2005.

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

The inspector 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

L and S Care 21/08/06

L and S Care 28/09/05

L and S Care 11/02/05

L and S Care 05/08/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 L and S Care 3 York Terrace Birchington Kent CT7 9AZ Lead Inspector Patrick Gough Announced 23 24 June 2005 rd th 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 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 Stationary 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. L and S Care H56-H05 S59423 L and S Care V226627 23062005 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service L and S Care Address 3 York Terrace, Birchington, Kent, CT7 9AZ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01843 227801 Miss Linda Ann Wright Care Home 3 Category(ies) of Learning Disability registration, with number of places L and S Care H56-H05 S59423 L and S Care V226627 23062005 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5/08/2004 Brief Description of the Service: 3 York Terrace provides residential care for 3 people who require varying degrees of assistance because of their learning disability. Whilst the Home does not purport to provide specialist services, it has access to all necessary specialist services within the community. The Home comprises a semi detached property in a residential area of Birchington and is within a short distance of amenities such as rail and bus services, health centres, shops and churches, a library and a concert hall. Staffing comprises the Registered Owner, a Manager and other support staff. L and S Care H56-H05 S59423 L and S Care V226627 23062005 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was conducted over two days and lasted for eleven hours. On both days the manager was present and there were three additional staff providing 1:1 care for the three residents. The three residents were in the Home at various times during the inspection. Four staff were interviewed over the two days and one resident was able to express his views on some aspects of the service provided. The three residents’ files, and other documentation relevant to their care, were examined. The staff were observed whilst engaging with the residents, at mealtimes and other times during the day. Policies and procedures were also checked. Three staff files were sampled to evidence how recruitment procedures were followed and to determine how they were supported in their role. What the service does well: The residents are accommodated in clean and comfortable surroundings and have sufficient communal space, including a small garden, to spend their leisure time. The quality of the food is good and there is sufficient quantity of fresh fruit either included in the menu or available outside of mealtimes. One resident stated that he enjoyed the food. There are a range of policies and procedures in place to support the practice and provide guidance for the staff. Residents are encouraged to maintain their independence through daily practice of life skills and are supervised and provided with assistance, where necessary, to make hot drinks and do their ironing. The staff have developed positive relationships with the residents and strive to promote effective communication. L and S Care H56-H05 S59423 L and S Care V226627 23062005 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: There are serious concerns that the recruitment procedures have not been followed and staff have been employed prior to the necessary checks being completed. This is a serious breach of regulations and the Home must stringently apply the agreed process with future applicants. Currently, the practice of staff, who have been appointed prior to the completion of the required checks, must be properly supervised and monitored to ensure that the residents are adequately protected and cared for. A serious concern letter has been issued and enforcement action may follow if the issue is not satisfactorily addressed. There was a lack of vital information relating to residents’ personal history on their file, and no indication of the reasons for referral and placement at the Home. This information should have been supplied by the Placing Authority prior to placement. There will be a requirement for the Home to actively seek to acquire this information from the relevant authorities so that a more complete account of the residents lives and achievements can be documented and so that the staff have all the required information to inform their planning. Whilst it appears that the Manager plays a prominent part in the supervision of practice in the Home there is no recognised system to regularly monitor and review the quality of care and the quality of management. There will be a requirement that reviews are conducted at the appropriate intervals, documented and reported to the Commission. The primary purpose of this practice should be to improve the service to residents. L and S Care H56-H05 S59423 L and S Care V226627 23062005 Stage 4.doc Version 1.30 Page 7 There were various instances where information was not adequately recorded. In discussion, the Manager gave examples of good practice, which had not been recorded in the residents files or daily logs. Additionally, where the Manager indicated that efforts had been made to address issues of concern there was no documented evidence to support those statements. It was recommended that all matters relating to the care of the residents and management of the Home is recorded appropriately. The role of the manager has not been clearly defined through a job description and there is no formal supervision available to address her management of the Home, her support needs or training needs. It is recommended that a job description is produced and formal supervision provided for the manager on a regular basis. The manager provides supervision for the rest of the staff, however there is no appraisal system in place and this should be introduced in order that staff performance and professional needs are addressed. The accommodation provided for the residents is clean and comfortable, however the appearance of the interior and exterior of the building could be improved through a redecoration plan. 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. L and S Care H56-H05 S59423 L and S Care V226627 23062005 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection L and S Care H56-H05 S59423 L and S Care V226627 23062005 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2,3,5 Whilst the needs of the residents have now been identified, initial admission material on the disability and needs of the residents was not provided and therefore compromised the service given to them. The staff are able to meet the needs of the residents enabling them to enjoy a good quality of life. The service user’s contract includes all the elements to maintain their access to the service and their rights. EVIDENCE: The three residents currently accommodated were admitted prior to the registered person acquiring the Home. There are no Care Management assessments on file and the manager confirmed that they were not available when she assumed responsibility. The Manager and staff have identified resident’s individual needs from information gleaned from resident’s relatives and from their own observational assessment. Although the residents have been at the Home for a number of years, there were no referral details and no explanation of their disability. There were no L and S Care H56-H05 S59423 L and S Care V226627 23062005 Stage 4.doc Version 1.30 Page 10 records of development or achievement prior to the current proprietor taking charge. A service user plan has been compiled for each resident based on the identified needs and interventions have been agreed. The staff were observed to be meeting the needs of the residents. One resident has the ability to communicate verbally and the staff were able to demonstrate how the other residents communicate and can be understood through pointing, other body language and Makaton. Good daily log recording and review reports indicate that the plan objectives feature in daily practice. Each resident has been issued with a service contract, which covers rooms occupied and use of other rooms in the house, terms and conditions of occupancy, personal support, fees and costs, rights and responsibilities and review of their needs. L and S Care H56-H05 S59423 L and S Care V226627 23062005 Stage 4.doc Version 1.30 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,9 The current care plan is implemented, monitored and reviewed within a timescale with the intention that the resident’s needs are addressed or practice altered. Despite communication difficulties, the staff have a good understanding of the resident’s needs and this was evident from the positive relationships formed with the residents. The residents are enabled to participate adequately, within the Home and in the community, through choice and decision-making opportunities and the assessment of risks. EVIDENCE: Each resident has a current care plan, which was updated on 28/05/05. The plan has headings, which include communication, personal care, dietary issues, health, restrictions on choice and freedom and social behaviour. It also features their likes and dislikes relating to food, leisure and general lifestyle. L and S Care H56-H05 S59423 L and S Care V226627 23062005 Stage 4.doc Version 1.30 Page 12 Although there are no formal 1:1 key work sessions recorded, the daily log completed at the end of the morning and in the evening, was found to be informative and reflected the main elements of the care plan. The Manager stated that the plan is monitored on a monthly timescale and the findings, as well as contributing to change or development, are contained in the six monthly review. However, this monitoring practice has not been recorded and there was a recommendation this should occur. As indicated earlier, in respect of initial admission material, there was no evidence of earlier care plans although the residents have been accommodated in the Home for a number of years. Two of the three residents have communication difficulties, however the staff were able to indicate how they were able to understand and interpret the resident’s mode of communication. The staff were observed to converse and interact positively with the residents throughout the inspection period. The inspector saw how residents were able to make choices at mealtimes and throughout the day, regarding activities and outings. There was no evidence of pre-admission risk assessments, however signed individual and generic assessments, stating the commencement and review dates, had been conducted. The assessments, which identified risk factors and action to minimise the risk, covered absconding, road traffic awareness, use of the kitchen, mealtimes, swimming, bathing and incidents in the community. Risk assessments conducted in 18/07/04 were reviewed on 17/01/05. It was recommended that risks are assessed following a serious incident or accident. L and S Care H56-H05 S59423 L and S Care V226627 23062005 Stage 4.doc Version 1.30 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,13,14,15,17. The residents are encouraged to maintain and develop their living skills through daily practice thereby promoting their independence. Regular planned use of community facilities and participation in events enable the residents to be purposefully engaged in community life. There are sufficient leisure opportunities provided by the Home to stimulate and fulfil the needs of the residents. The Home provides sufficient support to enable the residents to maintain regular contact with their family. The meals that are prepared, provide the residents with the requisite quantity and a balanced diet to maintain a healthy lifestyle. EVIDENCE: L and S Care H56-H05 S59423 L and S Care V226627 23062005 Stage 4.doc Version 1.30 Page 14 Each resident has 1:1 supervision and support at all times. They are motivated by the staff to maintain and develop their life skills and two residents were observed making toast and a hot drink during the inspection. The staff stated that the residents are encouraged to do chores, such as washing up and ironing. The residents participate in community life on a daily basis through walks, use of leisure facilities, shopping and various events. The Manager stated that the relationship with the neighbouring residents is good. Regular daily activities occur and include swimming and bowling. The Manager has sought the advice of a care manager and occupational therapist on the range of activities that might be available to the residents. There are occasional planed trips to leisure events, such as, for example, the visit to a circus attended by the three residents during the inspection. Consideration is given to relationships between the residents when planning such events so that the outcome is both safe and enjoyable for those concerned. In-house entertainment and activities are sufficient to engage the residents purposefully. There is a television, DVD player and audio equipment as well as various games, in the communal area, for the resident’s use. The staff have recognised that individual residents have specific interests and likes and have reflected this in their private accommodation. The residents are supported with their weekly contact visits and one resident has frequent visits from his family. The menus indicate that there is a varied selection of food prepared for the residents including fresh fruit, fresh vegetables and a variation of pasta, rice and potatoes. The food cupboards, fridges and freezers were well stocked. The mealtimes that were observed confirmed that there is adequate quantity and they were nicely prepared. One resident stated that the food is good and was seen to enjoy his meal. Staff were supportive at the meal table, assisting and advising as appropriate. Each resident’s weight is recorded on a monthly basis and included in their care plan. L and S Care H56-H05 S59423 L and S Care V226627 23062005 Stage 4.doc Version 1.30 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19 The Home provides sufficient staff to ensure that there is the required support and the residents benefit from 1: 1 assistance. The combination of adequate monitoring and the availability of the appropriate specialist resources ensure that the resident’s healthcare needs are met. EVIDENCE: The staff rota is organised so that there is 1:1 support for each resident, which allows for assistance to be given with personal care and life skills support. Where this is given it is evidenced in the daily log. The staff were observed to be engaging with the residents in a patient and sensitive manner. There is flexibility with bedtimes reflecting the choice of the individual resident; for instance, one resident prefers to go to bed early in the evening. The Home secures additional specialist support where necessary and currently involves a physiotherapist and occupational therapist in the care of the residents. Support is given to residents when accessing medical and hospital appointments. During the inspection one resident, in need of a change in orthopaedic footwear, was accompanied by a member of staff for a hospital appointment. L and S Care H56-H05 S59423 L and S Care V226627 23062005 Stage 4.doc Version 1.30 Page 16 L and S Care H56-H05 S59423 L and S Care V226627 23062005 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 The staff have the necessary procedure to follow in order to process complaints from residents or any other source. The staff have been trained and have the necessary guidance to provide the residents with adequate protection. EVIDENCE: The complaints procedure is included in the residents’ handbook and the Manager confirmed that the residents are helped to understand the process and to use it where appropriate. No complaints have been recorded as having been registered, however the Manager recalled an instance where a resident complained about ‘birds outside his window’, which was affecting his sleep and this resulted in a reorganisation of his room. Given the communication difficulties experienced by the residents, the inspector was concerned that residents’ anxieties or complaints may not be noted. The staff gave examples of the signs and symptoms which residents display when they are concerned about something. The Home has a whistle blowing policy and this is displayed prominently in the front entrance. The Home has an adult protection policy and procedures to be used in the event of a concern about abuse to the residents. The policy includes definitions of abuse, indicators of abuse and how to respond if there is a disclosure or L and S Care H56-H05 S59423 L and S Care V226627 23062005 Stage 4.doc Version 1.30 Page 18 concern. It also features information sharing, the importance of factual records and preventative measures. All the staff have signed to confirm that they have read the policy and seven of the eight staff participated in training in ’04 and ’05. L and S Care H56-H05 S59423 L and S Care V226627 23062005 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25.27 The Home is suitable for its purpose and adequately furnished enabling the residents to live in comfortable surroundings. The bathroom and toilet facilities are adequate but would benefit from refurbishment to improve infection control and make it more comfortable for the residents. EVIDENCE: The location of the Home, in a terrace of houses in a quiet cul-de-sac allows the residents to enjoy relative anonymity. The layout of the house, which has a self-contained basement flat, provides sufficient privacy and communal facilities for the residents. Both the exterior and the interior of the building is in need of redecoration. The Manager stated that there has been some difficulty in addressing some maintenance issues due to lease arrangements. The communal facilities, such as the lounge, dining room and the kitchen are comfortable and adequately equipped. The furnishings are clean and L and S Care H56-H05 S59423 L and S Care V226627 23062005 Stage 4.doc Version 1.30 Page 20 comfortable. There is sufficient space for the staff and residents with adequate natural light and ventilation. There is a separate toilet and bathroom, which has a bath with a shower attachment and a sink unit. The manager stated that the bathroom window, which has been temporarily repaired, is due to be replaced. The bath sill and window-sill will need to be repainted. The bedrooms of the two residents accommodated in the main house are spacious, well ventilated and are well equipped with built-in wardrobes, cupboard space, bedside cabinet and chair. The rooms are personalised. One resident is accommodated in a self-contained flat in the basement. The flat is clean and well furnished. The toilet and bathroom, which are easily accessible from the bedrooms, were clean and free from offensive odours. The floor covering, however could compromise infection control and the Manager was advised to consider alternative flooring. The toilet window, which needs to be accessed for ventilation, should be fitted with some form of restrictor, for safety purposes. A broken tile on the bathroom wall needs to be replaced. The requirement, made at the previous inspection, relating to the lock on the bathroom door has been addressed. L and S Care H56-H05 S59423 L and S Care V226627 23062005 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,34,35,36 The staff fully understand their role and responsibilities and this clarity of purpose provides consistency of practice with the residents. The staff approach the residents with respect and understanding, thereby acknowledging their needs and promoting a positive response. Recruitment policies have not been consistently followed resulting in residents receiving care from staff who have not been appropriately vetted. The training provided for the staff improves their skills and confidence in managing the care of the residents The Manager provides formal and informal supervision for staff enabling them to discuss and improve the quality of practice. EVIDENCE: Three staff files were examined and each one contained a job description, which outlined the main tasks. The content of the role description is linked to the Home’s aims and statement of purpose. The staff were observed to interact with the residents in a respectful and sensitive way, which generally achieved positive outcomes. Despite the L and S Care H56-H05 S59423 L and S Care V226627 23062005 Stage 4.doc Version 1.30 Page 22 absence of a personal history and diagnosis on the resident’s file the staff had a good working knowledge of each individual, enabling them to perform with a degree of consistency. Fifty per cent of the staff team have achieved NVQ level 2 qualification and two more staff have made application to commence training. The Home has a recruitment policy, which is in line with agreed guidance. The process has not however been followed and three staff, appointed in 08/04, 11/04 and 03/05, have not had a completed CRB check. Only one staff file contained two references, the other two had one reference each. A telephone check was conducted on the references of one member of staff. There were clear inconsistencies in the implementation of the recruitment process. The Manager stated that initial attempts to process the applications were unsuccessful because they had not been sent through an authorised ‘umbrella body’. Further delays were a matter of concern to her and following further requests from the Manager to the Provider, the applications were sent to CRB through a recognised body. There was no documentation supporting reasons for the delay. A further cause for concern was that the three staff who had not been properly vetted continue to practise unsupervised. The Manager stated that there is always a senior member of staff on duty with the three staff concerned. The Home has an induction-training package in place for new staff. There was evidence of this in the files although this similarly had not been satisfactorily completed in two instances. One member of staff indicated that there was a period of introduction to the role that involved accompanying a more experienced member of staff to observe their practice. The training matrix revealed that staff had participated in a range of training including adult protection, health and safety, first aid, food safety, manual handling and fire protection. The training plan indicated that further training is planned for 07/05 (care planning), 08/05 (risk assessment, challenging behaviour and infection control) and 09/05 (first aid). The Manager stated that formal supervision is given on a two-monthly cycle and recorded sessions on one file confirm that three supervision sessions have occurred in a six month period. A number of staff commented on the positive value of the support given by the Manager, Sarah Ducane. The Manager confirmed that she has no job description and does not receive formal supervision. L and S Care H56-H05 S59423 L and S Care V226627 23062005 Stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,39,40 The manager has not received the necessary support or guidance to enable her to perform her role effectively. There is insufficient monitoring by the Provider and the Manager, on a regular basis, to provide effective quality assurance and inform further planning and development. The Home’s policies and procedures support and guide practice enabling staff to engage confidently with the residents. EVIDENCE: The Manager has completed an NVQ Level 4 in Care and has experience as a care practitioner. The manager does not feature on the Home’s training matrix and in discussion it was agreed that she would benefit from a structured training programme commensurate with her responsibilities. L and S Care H56-H05 S59423 L and S Care V226627 23062005 Stage 4.doc Version 1.30 Page 24 There is no effective quality assurance system in place, although the manager produced a Regulation 26 format, which has yet to be implemented. The Manager has yet to introduce a system for reviewing the quality of care in the Home, in respect of Regulation 24. Following discussion on the format and required timescales the Manager confirmed that it would be introduced as required. The Manager stated that feedback is received from resident’s relatives and care managers but not documented. The residents were prepared for the inspection and there was evidence of the information leaflet in the Home’s entrance. The Home has a policies and procedures handbook, which contains all the relevant policies required. The staff were aware of the important policies and there was evidence in the handbook that they had signed to indicate that they had read them. There is input on the Home’s policies in the induction-training checklist. L and S Care H56-H05 S59423 L and S Care V226627 23062005 Stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 2 3 x 3 Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 x 2 x x x Standard No 11 12 13 14 15 16 17 3 x 3 3 3 x 3 Standard No 31 32 33 34 35 36 Score 3 3 x 1 3 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 L and S Care Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 2 x 2 3 x x x H56-H05 S59423 L and S Care V226627 23062005 Stage 4.doc Version 1.30 Page 26 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 2 Regulation 17 Requirement The Home must ensure that they access all the necessary information to ensure that the records referred to in Schedule 3 are included in the residents file. The Home must ensure that all the relevant checks, referred to in Schedule 2, are obtained before employment is commenced. The Registered Provider shall establish and implement a system for reviewing the quality of care provided at the Home and submit a copy of the review report to the Commission on a monthly basis. The Manager shall conduct a review of the care provided in the Home at appropriate intervals in order to assure quality of care and to improve the service and shall submit summary reports to the Commission on a quarterly timescale. Timescale for action 1/09/2005 2. 34 19 23/06/200 5 3. 39 24 1/08/2005 4. 39 26 1/08/2005 L and S Care H56-H05 S59423 L and S Care V226627 23062005 Stage 4.doc Version 1.30 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. 1. Refer to Standard 2 Good Practice Recommendations The Home should acquire all relevant information, from Placing Authorities, relating to the residents assessment of needs and any other personal history relevant to the compilation of the Service User plan. The Manager should conduct a risk assessment following serious incidents and accidents. The Registered Provider should create a planned maintenance programme to ensure that the exterior and interior of the premises is of an acceptable decorative standard. The Registered Provider should maintain the bathroom and toilet facilities to prevent spread of infection. The Manager should document how staff, whose recruitment checks have not yet been completed, are adequately supervised and monitored. The Registered Provider should ensure that the manager receives regular formal supervision. The Registered Provider should establish and implement an appraisal system for all staff. The Registered Provider should provide the Manager with a job description, which outlines the responsibilities and duties relevant to the role. The Manager should document and use the feedback received from residents relatives and visiting professionals to assist with quality assurance. 2. 3. 9 24 4. 5. 6. 7. 8. 9. 27 34 36 36 37 39 L and S Care H56-H05 S59423 L and S Care V226627 23062005 Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection 11th Floor, International House Dover Place Ashford Kent TN23 1HU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI L and S Care H56-H05 S59423 L and S Care V226627 23062005 Stage 4.doc Version 1.30 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. 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