Inspection on 20/06/08 for Langley House

This inspection was carried out on 20th June 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Langley House 05/07/07

Langley House 01/08/06

Langley House 02/03/06

Langley House 15/11/05

Langley House 31/03/05

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Langley House Langley Marsh Wiveliscombe Somerset TA4 2UF Lead Inspector Barbara Ludlow Unannounced Inspection 20th June 2008 12:30 Langley House DS0000060091.V365254.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 Langley House DS0000060091.V365254.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. Langley House DS0000060091.V365254.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Langley House Address Langley Marsh Wiveliscombe Somerset TA4 2UF 01984 624612 01984 624797 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) Voyagecare.com Voyage Ltd Manager post vacant Care Home 14 Category(ies) of Learning disability (14), Physical disability (1) registration, with number of places Langley House DS0000060091.V365254.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. There is a low doorway in the bedroom on the second floor within the three-bedded unit. This room is suitable only for service users who are less than 5 ft 2 in height. Registered for one named person with a learning disability and physical disability to reside within the main house. (Please see letter from CSCI dated 12/10/04). 5th July 2007 Date of last inspection Brief Description of the Service: Langley House is a large detached home set in its own grounds. It is registered with the Commission for Social Care Inspection to provide care for up to fourteen people between the ages of 18 - 65 years who have a learning disability. The home can also accommodate one client who also has a physical disability, within the main house - which has two ground floor rooms accessible for such clients. It also has eight first floor bedrooms. There is a separate annexe providing accommodation for up to three people, and a self-contained flat for one person, at the site. There was a vacancy for the registered manager position at the time of the inspection visit. There was an acting manager in place. Since the visit a manager has been appointed to the service. Fees at the home are determined on an individual basis dependant on assessed need. The inspector was advised the fees range from £1800 per week. Langley House DS0000060091.V365254.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of this inspection visit was to inspect relevant key standards under the Commission’s ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are: - excellent, good, adequate and poor. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection was undertaken by B.Ludlow for Commission for Social Care Inspection (CSCI). A site visit was made on 20th June 2008 to Langley House. There had been recent management change at the home. The acting manager, a registered manager from a sister home was on a training course but returned to the home when aware that the inspection visit was in progress. The acting manager then remained at the home to receive feedback at the conclusion of the inspection visit. The Annual Quality Audit Assessment (AQAA) was completed and returned to the Commission. Comment cards were sent out to the relatives of people living at the home and eight were returned to CSCI, analysis and comments received are included in the body of the report. The visit was well received. The home was found to be well organised and well managed. A significant amount of management work had been undertaken to address deficits that had been identified by the company; CSCI had been kept informed. Twelve people were in residence at the home. Eleven staff were on duty at the start of the visit as the shift handover was due. A tour of the premises was made with the acting manager. The home was clean, comfortable, well maintained and homely. Daily life at the service was observed. People living at the home and staff were seen and spoken with. People looked relaxed and well cared for. Staff interactions were friendly, polite and helpful. Care planning was sampled and was found to be person centred and up to date. Recruitment and staff supervision was examined and found to be up to date. Langley House DS0000060091.V365254.R01.S.doc Version 5.2 Page 6 Records for home maintenance were sampled and almost all were found to be up to date and complete. Feedback was given to the acting manager at the conclusion of the visit. The inspector would like to thank the people living at Langley House, their relatives and staff working at the home for their assistance with the inspection process. What the service does well: What has improved since the last inspection? The AQAA indicated that there has been an increase in staffing number in order to meet the planned activities for people living at Langley house. The number of staff on duty and the range of activities available evidenced this at the inspection visit. Langley House DS0000060091.V365254.R01.S.doc Version 5.2 Page 7 There is an ongoing redecoration programme to maintain the accommodation in good condition. Individual service plans (ISP’S) are being developed. These documents are detailed and very personalised plans. Two requirements and two recommendations made at the last inspection have been met. What they could do better: 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 Langley House DS0000060091.V365254.R01.S.doc Version 5.2 Page 8 be made available in other formats on request. Langley House DS0000060091.V365254.R01.S.doc Version 5.2 Page 9 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 Langley House DS0000060091.V365254.R01.S.doc Version 5.2 Page 10 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): 2 Quality in this outcome area is good. Admission is based upon a multidisciplinary assessment approach to ensure needs and aspirations can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no new admissions to the home since the last inspection. The people living at the home occupy a range of accommodation and have varied levels of support. All seemed to be appropriately accommodated and supported and were settled at the home. Each person has their own Statement of Purpose and the Service User Guide was written for the individual and forms part of their individual care planning documentation. Assessment would be made by the company specialist team and home manager. Assessment visits to the home are part of the assessment if appropriate to the person concerned. Care Managers and families or advocates are included and involved to ensure the placement is positive choice for the person concerned. Langley House DS0000060091.V365254.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. Care planning is person centred and reflects that people are enabled to lead active lives. Individual risk assessments are undertaken to ensure the level of support they need is provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care planning was examined for four people. Two care plans were looked at in detail and two others to review risk assessments and challenging behaviour management guidelines, these well reported and very thorough. Care plans had day-to-day information and detailed monthly summaries. Medical information was well recorded and involvement from health care and allied health care professionals was also well recorded. Langley House DS0000060091.V365254.R01.S.doc Version 5.2 Page 12 People living at the home have Individual Support Plans that hold their personal information, family and friends networks and their preferred daily routines. There was clear participation with this and the plans were person centred. Likes and dislikes, interests and hobbies were recorded. Other information included their health care and physical and health risk assessments. Challenging behaviour was well documented and management strategies were recorded. Each person has their own Statement of Purpose and the Service User Guide written for them and forming part of their individual care planning documentation. All the people living at Langley House have a designated key worker. The role of the key worker is explained in the individuals support plan. Staff spoken with demonstrated a good knowledge and understanding of the people for they care for and for those they key work. Examples of communication were given for people who are non-verbal. Staff were seen to communicate skilfully, with patience and with good insight and understanding. Staff and people living at the home were cheerful and heard laughing together. There was a calm and relaxed atmosphere at the home. People are given choices with every day living. People have some routines for example those attending a venue away from the home, getting up and breakfast are timed to suit them. For others there is no set regime but there are activities each day. Each person has a daily plan to refer to in his or her individual support plan. Risk assessments are in place and where people have health related risks or exhibit behaviour that can challenge, they are recorded in detailed and are reviewed and updated. At the last inspection it was reported that no service user manages his or her own finances. The company acts as an appointee for 5 service users and the home holds personal finance for all service users to ensure that they are able to access their money at all times. The records for finances were inspected and examples of the procedures for money coming in and money going out and being receipted were seen. Any money held on behalf of an individual is regularly tallied and the check signed. Any money is stored securely and access is safely managed. Resident meetings are held the most recent was on 14th June 2008; eight people living at the home and six staff attended it. A support worker chaired the meeting. Langley House DS0000060091.V365254.R01.S.doc Version 5.2 Page 13 Feedback from relatives was positive about the choice of home and their relatives needs being met. One commented that re assessment was organised for changing needs and another said that ‘needs are met in a caring and sensitive way’. Langley House DS0000060091.V365254.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good The people living at Langley house have care plans that included their social activities, hobbies and interests. Activities are arranged to allow the individuals to lead full lives. Routines are varied and take account of people’s day-to-day preferences. The catering was adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People have varied and interesting lives and some spoke to the inspector about the things they do each week. Those who required supervision were attended throughout the inspection day in line with their support and care plan. Langley House DS0000060091.V365254.R01.S.doc Version 5.2 Page 15 Challenging behaviour is well managed and staff had a good understanding of the people they care for and the support they need. Exercise is encouraged, three people had been out to swim at another home and the inspector heard of one person that enjoys country walks and trips out to the beach. There is an activities coordinator, in house activities are organised. The staff said the ensure activities happen and that something is planned for everyone. There was sufficient staff on duty to meet the support needs of the people at Langley house. Contact with families and friends are encouraged. Calls if required are made or supported to family and friends on a regular basis. Feedback from relatives indicated that communication is usually good but that at times weekly calls have not been made when requested and that communication between staff may have been lacking when one thought the other had spoken with or made contact with relatives. Important issues are communicated such as ill health, this was reported to be made promptly with regular follow up on progress. Holidays are arranged and taken; the inspector heard that there are plans for a week’s chalet holiday to Cornwall in September. The planned holiday will be for three people for three days and then three to four people for the rest of the week. Staff go along to support the people on holiday. The inspector heard that staff at the home are always willing to go along to support people on residential holidays. The menu is agreed with the people living at the home and follows a five-week menu that is changed seasonally. A member of staff is designated each day to cook. Staff also attend to the shopping and catering for the home in line with the menu planning which is what the people chose to eat. CSCI had received an anonymous concern that the quality of the food was poor and that snacks were not always available. The acting manager commented that individuals have their own snack food, which is stored separately from the communal food, to be accessed when the individual wishes. The food seen in the store was basic both in quantity and quality, being supermarket cheaper branded foodstuffs. The budgets for food are sufficient for a quality diet to be catered at each mealtime. It was apparent that supplies had been reduced and the food had been purchased for one or two days at a time. Tins was stacked together and labelled according to the meal they were for. The acting manager agreed to explore the quality of the food being purchased to ensure the standard was sufficiently high. Staff at the home eat with the people living at the home. Langley House DS0000060091.V365254.R01.S.doc Version 5.2 Page 16 No complaints or other concerns were raised with CSCI by people, their families or their friends. Langley House DS0000060091.V365254.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is good Care and support is person centred and staff have a good level of knowledge of the people they support. Care is holistic and attention is paid to the individual’s physical and emotional health care needs. Medication is safely managed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each person has a detailed care plan and individual support plan. The care plans are made in agreement with the person and reviews involve significant people involved in their care and their family if they wish. Daily records are made on the day-to-day form and are filed month by month after being summarised. The individual service plans (ISP’s) seen had photographic identification, personal details, friends and family network and a Langley House DS0000060091.V365254.R01.S.doc Version 5.2 Page 18 preferred daily routine. Likes and dislikes were noted and interests and hobbies. This is where a weekly plan of activities is kept and relevant health information such as health risk assessments for epilepsy and challenging behaviour. The statement of purpose and personal service user guide is kept with the ISP; there is also a leaflet about abuse to raise awareness. The AQAA stated that the ISP will include Local GP contact, practical information such as the level assistance required with bathing and also final wishes regarding ageing, illness and funeral arrangements. Missing person information is kept with disclosure guidelines for staff. There is also a traffic light system, which is used for hospital admissions to ensure the right actions are taken and the right information and support go with the person in need of urgent care. Correspondence and contact with parents / next of kin is logged onto the care plan records. Health care information included evidence of dental health care appointments, weight monitoring, and preferences for the gender of staff delivering their personal care. The chiropodist visits the home each month. On the day of the inspection a visiting therapist was attending the home to see people who required massage therapy, this is provided with no extra charge. All relatives asked responded positively. Two relatives commented that personal care as nails, hair and teeth could be attended with support more regularly, the difficulty with cooperation was recognised. This was brought to the attention of the acting manager at the inspection. All people looked clean and well presented at this unannounced inspection visit. Comment also included how happy and content people are living at Langley House. Families also commented on the choices available to their relative and the appropriate outings and activities. Staff spoken with demonstrated a thorough knowledge of the people they care for. Staff are well trained to meet the needs of people they care for. The company has introduced the L Box computer training to ensure timely training for all staff on important areas such as safeguarding vulnerable people in their care. Staff are trained in Non Violent Crisis Intervention (NVCI) to enable behaviour that may challenge staff to be dealt with without any risk of injury to the person concerned. The AQAA indicated that work on the ISP’s is part of the strategy to do better and that this will continue over the next twelve months, as staff develop their use at the home with the individual people in their care. Senior staff receive a one-day training course in the administration of medication and other care staff undertake half a days training in this area. Langley House DS0000060091.V365254.R01.S.doc Version 5.2 Page 19 Medication administration records were seen. The charts have photographic identification. There are individual instructions and all entries were signed for. Two hand transcribed entries had no signatures and four entries had only one signature. Two signatures are recommended as good practice, to demonstrate that the entry was checked and validated as correct by the second person. Langley House DS0000060091.V365254.R01.S.doc Version 5.2 Page 20 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 Quality in this outcome area is good People are listened to and valued at Langley House. Good care practice and policies and procedure are in place to safeguard people for the risk of harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a complaints policy and procedure. Any concerns raised by the commission have been promptly dealt with. CSCI received one concern this year this was dealt by the company, in a timely and appropriate manner. A more recent concern raised at the home is undergoing investigation by the manager the outcome of this was not known at the time of the inspection. A conclusion is required in response to the inspection report. One relative raised concerns about activities and locking a bedroom door for their relative, the inspector was advised that this has been dealt with. Staff receive training in the protection of vulnerable adults and the home has whistle blowing and abuse policies. There have been no referrals made to the POVA list. The staff also receive training on complaints and the ‘let us know what you think policy’. Langley House DS0000060091.V365254.R01.S.doc Version 5.2 Page 21 The AQAA demonstrated that as a result of listening to people who live at the home that they have increased the staffing number. The feedback from relatives indicated that they all would know how to make a complaint about the care. Regarding the response to concerns raised 2 said they would always be responded to appropriately, 5 said usually. Langley House DS0000060091.V365254.R01.S.doc Version 5.2 Page 22 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good The home is kept clean, tidy and well maintained. Staff have received training in infection control. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises was made. The grounds have attractive well-managed gardens and fields of five acres. The rear gardens are safe and outdoor activity is supported. The AQAA stated that the development of the five-acre grounds is planned to introduce gardening and other pursuits. The home is divided into three areas and the staff team work across these areas giving support at different levels. The home was seen to be clean and well maintained. One storeroom had a damp ceiling. The individual Langley House DS0000060091.V365254.R01.S.doc Version 5.2 Page 23 accommodation has been adapted to meet the needs of each person and all can be locked by keypad if they wish. All bedrooms have ensuite facilities to meet the needs of the individual. The laundry is well managed with photo identification on the plastic clothes boxes for each person. The staff stated that there are plans to install a washer dryer in the part of the home known as the flat. The three-bedded wing has separate laundry facilities to the main house. The kitchen was very clean; staff and people living at the home eat together. The AQAA stated that there are plans to continue to make the home more personalised. The redecoration of the home and individual bedrooms will continue and there are plans for new flooring covering for the lounge, some new stair carpet and new lounge furniture. Staff have a secure office area and managers office. There is also accommodation on site for the ‘sleep in’ duty in one part of the home at night. Families responding to CSCI expressed their satisfaction with the service. One comment raised was that it would be helpful for the home to have professional cleaners in once in a while, to clean the bedrooms as the cleaning tasks are undertaken by staff and have to fit in with their other duties. Other feedback included that one person felt their relative was very happy with their surroundings. Another stated that their relative needs were met with ‘security, comfort and stress free living’. Langley House DS0000060091.V365254.R01.S.doc Version 5.2 Page 24 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is good The staff team are capable and receive a good level of induction and training. The homes recruitment practice is sound. A skill mixed team was on duty to meet the needs of people in their care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There was twelve staff on duty at the start of the inspection visit, which was just ahead of the changeover period. Staff were spoken with, they demonstrated a good knowledge of the people they care for and those for whom they are designated as key worker. There was a good atmosphere and people were heard laughing together with staff and were observed being treated in a friendly manner. Throughout the inspection visit staff were heard to be helpful and kind in all their interactions with the people in residence. Langley House DS0000060091.V365254.R01.S.doc Version 5.2 Page 25 The AQAA indicated that there are 32 full time support workers and 14 part time support workers and an additional 16 non-care staff working at the home. The staff with a Non Vocational Qualification (NVQ) was 56 , this includes the staff currently working towards the award. 9 staff have left the service in the last twelve months. Applications had been received for recruitment to the current vacancies. Staff recruitment files for four staff were sampled. These files were satisfactory, the evidence confirmed that application forms had been completed and references taken up. Enhanced Criminal Record Bureau (CRB) checks with POVA first checks had been undertaken. There was photo identification and job descriptions for each staff. Induction and training certificates were seen and supervision had been undertaken at regular intervals. The AQAA indicated the company commitment to providing well-trained staff to care for the people at Langley House in particular the supporting of staff to undertake NVQ training increasing the number of NVQ qualified staff over the next twelve months. Staff meetings are held and the minutes are held in file. The minutes of one meeting were seen and these were quite detailed. No complaints were heard about staffing levels. The nighttime staffing is four waking and one sleepover member of staff on duty. The training plan and five staff training records were seen, they indicated that one staff requires POVA training, one first aid and two possibly three staff required manual handling training to bring them up to date. The records indicated that all staff had received recent fire training. Feedback from relatives was very positive about the staff working at the care home. They are described as ‘ very caring’, the home has ‘lots of experienced staff’, another felt that ‘some are better than others’. One person appreciated that the staff team has younger members of staff that offer ‘youthful rather than motherly care’ and the home is good at ‘recruiting staff of a similar age group’. One other stated that ‘the staff are the best asset of the home’ Langley House DS0000060091.V365254.R01.S.doc Version 5.2 Page 26 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, 42 Quality in this outcome area is good The home was managed and there was a good level of company senior management support. The home is developing with the best interests of the people living at the home in mind. The health and safety of people living at the home is promoted by good practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Langley House DS0000060091.V365254.R01.S.doc Version 5.2 Page 27 There had been recent management change at the home. The acting manager is a registered manager from a sister home who had been seconded to manage the home until the new manager was settled into their post. The acting manager returned to the home from a training course to assist with the inspection process. This was most helpful as many records that have restricted access would have been in accessible. The acting manager had undertaken significant pieces of work and the result was a demonstration of record keeping and management that was well organised and efficiently managed. There had been some audit and input by the senior management of the company. Regulation 26 visit records were seen to support this. The acting manager and the operations director for the company had completed the Annual Quality Assurance Audit (AQAA); this was received at CSCI in a timely manner for the inspection report. The AQAA stated that support for the incoming manager would be given over the next twelve months. The acting manager had dealt with reviews and care management using her expertise to the benefit of the people living at the home. Changes have been made as a result of feedback from people who use the service. An example quoted in the AQAA was the increase in staffing number and the additional role of an activities person to meet the activities and support the needs of the people in residence. Health and safety was well managed, records were inspected to confirm some aspects of this. These included the fire training records: A fire safety risk assessment was completed in June 2007 and was reviewed in April 2008. The home was in the process of identifying emergency accommodation, which is recommended by the fire service in case of evacuation for any reason. Fire safety equipment had been serviced and visual checks had been recently made. Staff are given fire training at six monthly intervals, records were seen for January 2008. The AQAA indicated that some policies and procedures may need to be reviewed for example the accident policy was last reviewed in 3/04, infection control in 3/05, moving and handling was 3/04 and smoking and staff grievance 4/06. These policies need to be reviewed. Langley House DS0000060091.V365254.R01.S.doc Version 5.2 Page 28 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 X 2 3 3 X 4 X 5 X 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 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 X 3 4 3 X X 2 X Langley House DS0000060091.V365254.R01.S.doc Version 5.2 Page 29 YES 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 YA42 Regulation 13(6) Requirement All staff must be provided with all mandatory training, including Safe Handling, and updates as they become due. (Previous timescale of 28/02/07 and 01/11/07 not fully met) This refers to the staff training identified as required in first aid, manual handling updating and POVA training. The quality and quantity of the food available for providing a balanced and healthy diet for the people in residence should be revised and improved. Timescale for action 30/09/08 2 YA17 16(2)(i) 30/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA32 YA32 Good Practice Recommendations All staff should receive training about the implications for practice of the Mental Capacity Act 2005. 50 of care staff should be trained to NVQ level 2 or DS0000060091.V365254.R01.S.doc Version 5.2 Page 30 Langley House above. 3. YA40 Policies should be reviewed annually and any changes made to key areas such as required by changes to the law for example: smoking regulations. Langley House DS0000060091.V365254.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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