Inspection on 27/07/07 for Larklands And Church View

This inspection was carried out on 27th July 2007.

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 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Larklands And Church View 14/06/06

Larklands And Church View 21/09/05

Larklands And Church View 13/04/05

Larklands And Church View 27/10/04

Larklands And Church View 11/05/04

Larklands And Church View 13/01/04

Larklands And Church View 01/10/03

Larklands And Church View 04/06/03

Larklands And Church View 23/07/02

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

CARE HOME ADULTS 18-65 Larklands And Church View St Johns Road Ilkeston Derbyshire DE7 5PA Lead Inspector Tony Barker Unannounced Inspection 27th July 2007 09:00 Larklands And Church View DS0000002171.V341267.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 Larklands And Church View DS0000002171.V341267.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. Larklands And Church View DS0000002171.V341267.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Larklands And Church View Address St Johns Road Ilkeston Derbyshire DE7 5PA 01522 560950 0115 932 3209 churchview@unitedhealth.co.uk www.unitedhealth.co.uk United Health Limited 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) David Wagstaff Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Larklands And Church View DS0000002171.V341267.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th June 2006 Brief Description of the Service: Church View and Larklands is a purpose built care home with nursing offering 10 places for adults with a severe learning disability, set in 2 bungalows. It is close to the town centre of Ilkeston with easy access to local facilities. Its physical environment was designed for the current group of residents who were all admitted in 2000 as part of the closure of Aston Hall Hospital. Because of the high levels of learning disability in the resident group the Home offers an intensive package of support and the number of staff is accordingly set high. Its fees are currently between £1197 and £1227 per week. A copy of the Home’s Statement of Purpose, and of recent years’ inspection reports from the Commission for Social Care Inspection (CSCI), are available to service users and visitors in a folder in the entrance lobby of Church View. Larklands And Church View DS0000002171.V341267.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 8.25 hours and was a key unannounced inspection. The service users all had high levels of dependency and therefore were not able to contribute directly to the inspection process, though they were observed working with and being cared for by staff. The Manager, Deputy Manager, one social care worker and Activities Co-ordinator were spoken to and records were inspected. There was also a tour of the premises. One service user was case tracked so as to determine the quality of service from their perspective. This inspection focussed on all the key standards and on the progress made towards achieving the requirements and recommendations made at the last inspection. The pre-inspection, Annual Quality Assurance Assessment, questionnaire was reviewed prior to this inspection. What the service does well: What has improved since the last inspection? What they could do better: Care/Action Plans must be reviewed regularly to ensure that residents’ current needs are being met. A written protocol, on the use of ‘as and when required’ medication, must be provided in respect of all residents who are administered medication in this way. All staff who handle food must be provided with training in Basic Food Hygiene. All staff must be provided with training in Moving & Handling, First Aid and Fire Safety. The company must provide the Larklands And Church View DS0000002171.V341267.R01.S.doc Version 5.2 Page 6 Manager with regular formal, planned supervision so as to ensure a quality service is being provided to residents. The views of residents’ relatives and others involved in residents’ lives must be periodically sought regarding the quality of service provided. Risk assessments of the environment must be carried out and periodically reviewed to ensure the safety of all residents and staff. 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. Larklands And Church View DS0000002171.V341267.R01.S.doc Version 5.2 Page 7 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 Larklands And Church View DS0000002171.V341267.R01.S.doc Version 5.2 Page 8 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. This judgement has been made using available evidence including a visit to this service. Individual written needs assessments were in place before people were admitted to the Home so that their diverse needs were identified and planned for. EVIDENCE: All the residents were admitted to the Home in March 2000. Information gained at previous inspections, from the examination of individual files, indicated that residents had extensive assessments of their requirements carried out before they came to the Home. The process of assessment had continued after the residents had settled at the Home, with additional inputs from outside professionals. Larklands And Church View DS0000002171.V341267.R01.S.doc Version 5.2 Page 9 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. This judgement has been made using available evidence including a visit to this service. Residents had individual plans of care which demonstrated that their health, personal and social care need were being met, although these plans were not being frequently reviewed. A ‘person centred’ approach was being taken to ensure that residents’ unique needs were focussed on. EVIDENCE: The file of the case-tracked resident was examined. Action Plans were well worded and extensive in their coverage of personal health and behavioural needs. However, they were not being reviewed regularly – many were last reviewed in January 2006. The file contained useful ‘person centred planning’ (PCP) documents, dated January 2005, including, ‘My way of talking’, ‘My feelings’ and ‘Things I am really good at’. The Manager explained that the case tracked resident was one of a small number at the Home, whose needs had been recorded using a ‘person centred’ approach. He said the Home had taken the initiative to introduce these ‘person centred’ documents and he knew of no plans for United Health to support this approach. Each resident had a Life Story Book that also took a ‘person centred’ approach and provided a Larklands And Church View DS0000002171.V341267.R01.S.doc Version 5.2 Page 10 valuable record for staff. Residents’ social and emotional needs were well recorded in these Life Story Books and in the PCP documents but had little mention in the Action Plans. Therefore, whilst it was clear that the Home’s day-to-day practices and activities were ‘person centred’, recorded care planning objectives did not underpin all these activities and this limited the opportunities to evaluate many of them. The social care worker spoken to gave examples of residents making their own decisions and choices, with staff assistance. These included one resident making clear their wish to watch a film and pointing at one DVD out of a small selection offered. She added that two residents were able to choose their own clothes, with help. Recorded risk assessments were of a high standard and appropriately included elements of risk management. There was evidence, during this inspection, that risk management was not just a paper exercise. Some risk assessments had been developed in 2006 – others had been developed earlier. There was a ‘Risk Evaluation’ sheet indicating reviews of these risk assessments. However, this was just a ‘tick list’ and did not prompt staff to comprehensively review the risk assessments. Discussion with the social care worker indicated that the Home was regularly practising ‘responsible risk taking’ to enable residents to develop confidence in daily activities. The use of a swing, with harness, in the garden was given as an example. The worker spoke of covering ‘responsible risk taking’ during her induction training. Larklands And Church View DS0000002171.V341267.R01.S.doc Version 5.2 Page 11 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. This judgement has been made using available evidence including a visit to this service. The Home provided activities and services that were age-appropriate and valued by residents and promoted their independence. EVIDENCE: There was evidence of residents taking part in valued and fulfilling activities. For example, the social care worker reported that one resident “loves the garden swing and goes straight to it”. Another resident uses signs to show a wish to go out in the Home’s minibus or to the swimming pool. These are two regular activities. A full time Activities Co-ordinator is in post and she described to the Inspector how she accompanies residents shopping, on walks, on trips to local parks and to the swimming pool. She also spends time with residents in the Art Room in Larklands. She does not take on the sole responsibility for providing social activities for residents – the Manager spoke of her facilitating and supporting staff in this role. The social care worker confirmed this in conversation. A Weekly Activities Board highlights each resident’s daily activities and files contained ‘Activities Social/Leisure’ sheets, Larklands And Church View DS0000002171.V341267.R01.S.doc Version 5.2 Page 12 providing valuable written feedback on these daily activities. All except two residents - one on personal health grounds and one by choice - were being provided with at least one holiday a year, with a two to one staffing ratio. The social care worker described how residents walk, with staff, into town where they go to the barbers, shop in local supermarkets, drink and eat in local pubs and spend time in Shipley Park and other local places of interest. The local swimming pool was just 10 minutes away and popular with residents. Public transport was used and the Home had a minibus too. The Manager spoke about his plans to become more involved in the local learning disability ‘community’. Family contact with some residents was regular while with others it was limited, the social care worker reported. Two residents had no family contact, she said. Relatives visited the Home and often took residents out. On the day of this inspection one set of relatives was visiting and they spent time talking to other residents too. While residents generally related to staff, within the Home, there was evidence of a close relationship between two residents who had known each other at Aston Hall Hospital before their admission to the Home. The social care worker provided evidence of daily routines promoting residents’ independence. These included bathing and showering routines, bringing in and putting away the shopping and putting ironed laundry away. All residents needed some degree of prompting as part of their personal daily routines and some required physical help – with dressing or toileting, for example. Each bedroom door was lockable and keys were kept outside the room, either in the door lock or hung beside the door. Residents had unrestricted access to their rooms. Hot and cold water supplies, to all taps to which residents had access, were controlled by a key-operated switch. Some residents were prone to drink excessively and this system addressed their personal safety, as well as minimising the risk of flooding. Key pads were fitted to a number of doors to address residents’ safety and hygiene. Residents’ levels of disability precluded them having allocated housekeeping responsibilities although the Manager explained that some residents would bring back their cleared plates to the kitchen. Food stocks in the kitchen were at a good level and included fresh fruit and vegetables. A rolling menu was examined and this showed that residents were being provided with a varied and nutritious diet. Individual food diaries provided a record of food actually eaten and of food preferences – particularly important for those residents with dietary needs. Several ‘theme nights’ a year were held, the Manager reported. Larklands And Church View DS0000002171.V341267.R01.S.doc Version 5.2 Page 13 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. This judgement has been made using available evidence including a visit to this service. The Home was providing residents with personal support in the way they preferred and required and was meeting their physical and emotional health needs. EVIDENCE: The social care worker described how residents’ privacy and dignity were respected. She spoke of residents being asked if they wanted to keep their bedroom door open and also gave examples showing how daily routines were flexible. For example, residents will have a ‘lie-in’ in the morning if they have had a poor night’s sleep. She added that the routine was “relaxed” and said that residents will normally get themselves up in the morning though they may need prompting by staff at mid morning. Equipment was in place to maximise residents’ independence included two ‘Parker’ baths and one walk-in shower, a ‘Rotunda’ transfer platform for the use of one resident, eating aids and a ‘Rompa’ swing seat in the garden. The use of photographs or other means to make a pictorial representation of food - to further enable residents to make choices and decisions about what they eat - was again discussed with the Manager. An advocate from Derby Advocacy Service was involved with all the residents and was attending each of the formal six-monthly care plan review Larklands And Church View DS0000002171.V341267.R01.S.doc Version 5.2 Page 14 meetings. This advocate was currently pressing for a local hydrotherapy resource and access to ‘Treatment & Assessment’ beds in this part of Derbyshire, the Manager reported. During the inspection, staff were observed talking respectfully to residents. The case-tracked resident’s file showed details of a good range of external health professional contacts and provided evidence of health appointments being met and the resident’s health needs being well considered. A health information sheet was on file to be taken with a resident to hospital should the need arise. Some of the residents had complex health problems and the nurses and care staff were supported by the local GP practice. A Macmillan Nurse had been visiting the Home regularly for the past three years – providing advice to staff on symptom management regarding one resident’s cancer. At the last inspection she had spoken positively to the Inspector about her relationship with the Home, referring to “good team working”. One resident had been provided with a ‘ripple mattress’, and a specialist chair, and these had successfully prevented the occurrence of pressure sores. This resident had also been provided with bed rails eight weeks prior to the inspection. Although a risk assessment, relating to these rails, had not yet been completed the Manager showed awareness of the potential hazards of their use and spoke of an occupational therapist being involved from the beginning. Medication Administration Record (MAR) sheets were examined and were satisfactory. There was a record of sample nursing staff signatures/initials and photographs of each resident, to minimise mistakes. The Manager described generally good medication practices with audit trails. A notification had been received by the Commission in August 2006 following overmedication of one resident by a member of nursing staff. This had been managed well by the Manager, through providing this member of staff with a one-to-one two-day refresher course in the safe use of medication and monthly supervision as necessary. There was discussion with the Manager over the benefits of providing all nurses at the Home with refresher training on the safe use of medicines. Several residents were being administered medication on a ‘prn’ as and when required – basis. These occasions were being clearly recorded – an improvement from the last inspection. However, it was still the case that not all residents had protocols for the use of ‘prn’ medication – there was none, for example, relating to the use of ‘prn’ diazepam for the case tracked resident. The Home’s ‘Administration of Medicines’ policy made no reference to the administration of ‘prn’ medication. The administration and recording of controlled drugs was satisfactory. Medication was being safely stored. Larklands And Church View DS0000002171.V341267.R01.S.doc Version 5.2 Page 15 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. This judgement has been made using available evidence including a visit to this service. Good procedures for handling complaints and abuse were in place ensuring residents were fully protected. EVIDENCE: The Home had a comprehensive complaints procedure. A satisfactory recording system for complaints received was on computer in the Home’s office. This appropriately addressed complainants’ satisfaction with the outcome. The Manager reported that there had been no formal complaints made by anyone within the past 12 months. All residents had external professionals, and an advocate, looking after their interests. There had been one ‘safeguarding adults’ alert sent to the local Social Services office since the last inspection, although this did not actually trigger ‘safeguarding adults’ procedures. The Home was seen to have followed good practice on this occasion. The Home’s Deputy Manager had undertaken a ‘training for trainers’ course in ‘Safeguarding Adults’ and had trained two members of staff. All staff, including the Manager, had now undertaken this training. The Company’s written procedures on ‘Safeguarding Adults’ were brief and referred to Derbyshire’s procedures for more detail. A copy of these were being held at the Home. A comprehensive Whistle Blowing policy was seen and the social care worker spoken to showed awareness of this policy. She also spoke of having received training on ‘Safeguarding Adults’. Larklands And Church View DS0000002171.V341267.R01.S.doc Version 5.2 Page 16 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. This judgement has been made using available evidence including a visit to this service. Residents were living in a clean, safe and well-maintained environment, which was furnished and decorated to a good standard. EVIDENCE: Environmental standards were good at this Home, particularly considering the challenging behaviour of some of the residents, and there was no institutional feel to the environment. The Home was nicely decorated and was homely. The social care worker spoke positively of her workplace, saying, “It feels like a home”. The bedrooms seen were well personalised. All bedrooms had a lockable drawer. The Home had a comprehensive Infection Control policy and the social care worker spoken to described good practice regarding the movement of infected material within the Home and its disposal. There was a sluicing sink in each laundry room as well as a washing machine and dryer. Of the five bedrooms in Larklands, two were carpeted and three had good quality vinyl flooring to Larklands And Church View DS0000002171.V341267.R01.S.doc Version 5.2 Page 17 enable easy cleaning. The Home was clean and hygienic with no offensive odours. Larklands And Church View DS0000002171.V341267.R01.S.doc Version 5.2 Page 18 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): 32,33,34,35 & 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels were high and staff were well-recruited but inadequate staff training put residents at risk, potentially. EVIDENCE: Seven of the seventeen social care staff had achieved a National Vocational Qualification (NVQ) to level 2 or above. This did not meet the National Minimum Standard to maintain a staff group with at least 50 qualified staff and was less than at the last inspection. Staffing levels were high to reflect the high dependency needs of the resident group. The Manager said that the staff group was at full establishment, with one nurse and three social care workers having been appointed within recent weeks. Records confirmed that very few agency hours had been needed over a recent three-month period prior to this inspection. One nurse and eleven social care workers had left employment in the Home in the last 12 months. This was a fairly normal rate of turnover, the Manager said, and there was no evidence of job related dissatisfaction. The staff rota indicated that some staff were still working long hours – a regular 72 hours over 6 consecutive nights in the case of one member of staff. The Manager stated that this was at the staff Larklands And Church View DS0000002171.V341267.R01.S.doc Version 5.2 Page 19 member’s request and assured the Inspector that she was not over worked and had not had any sick leave. It was noted that there was a mix of part time and full time staff, giving flexibility as well as consistency. The file of a recently appointed member of staff was examined. Matters relating to her recruitment were all satisfactory and Criminal Records Bureau (CRB) checks were all in place. All staff had received a copy of the General Social Care Council’s (GSCC) Code of Conduct. The Manager spoke of having no problems recruiting staff. The Induction Record of two newly appointed staff was examined and indicated that they had received induction to Skills for Care Common Standards. The Manager stated that staff work a three-month probationary period before being put forward for NVQ level 2 training. The Home had ‘training matrix’ providing an at-a-glance view of staff training undertaken and needed. This showed that approximately half of the staff group needed training in Basic Food Hygiene, Moving & Handling and First Aid. Whilst most of the staff group work night shifts at some time none had been provided with two sessions of fire training within the past 12 months. The Manager said he felt that the shortfall in staff training was because of the loss of the Home’s Deputy Manager. He stated he and one other nurse had a professional training certificate and he was still planning to provide staff with training on topics such as diabetes, epilepsy and autistic spectrum disorders. The Manager commented that he receives no formal, planned supervision from his line manager and feels that lack of a supportive and informative network within the Company, relevant to the service provided by this Home, leaves him feeling somewhat isolated. The frequency of supervision provided to the staff group was not assessed on this occasion. Larklands And Church View DS0000002171.V341267.R01.S.doc Version 5.2 Page 20 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): 37,39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Home was not adequately monitoring its quality of service and so it could not be assured that residents’ needs were being fully or appropriately met. EVIDENCE: The Manager had worked at the Home since August 2003 and been Manager since February 2004. He qualified (Registered Nurse in Mental Handicap) in 1994 and completed his NVQ level 4 in management in March 2006. The Company had a quality monitoring system based on monthly audits by the Home’s line manager. Some of these were examined and they were found to be satisfactory. However, there was a gap of three months in the records, between February and June 2007. An Annual Plan had been developed for the Home and this was examined. It covered a useful range of topics but it was not dated and did not indicate any timescales for achievement, as at the last Larklands And Church View DS0000002171.V341267.R01.S.doc Version 5.2 Page 21 inspection. Satisfaction questionnaires had been sent to relatives two years ago but none since. No other groups, such as external professionals, had been sent a questionnaire as part of the Home’s quality assurance system. There was evidence that the Home’s quality assurance system had not received much priority within the last 12 months. Cleaning materials were being safely stored in locked cupboards. Good food hygiene practices were being followed, including safe food storage. There were no periodic health & safety checks being made of the Home’s environment or an environmental risk assessment in place. Records of regular fire drills and weekly fire alarm tests were in place. Electrical and gas equipment was being checked at appropriate intervals. Larklands And Church View DS0000002171.V341267.R01.S.doc Version 5.2 Page 22 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 3 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Larklands And Church View DS0000002171.V341267.R01.S.doc Version 5.2 Page 23 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 YA6 Regulation 15(2)(b) Requirement Care/Action Plans must be reviewed regularly to ensure that residents’ current needs are being met. A written protocol, on the use of ‘prn’ - as and when required medication, must be provided in respect of all residents who are administered medication in this way. These protocols must be explicit in order to minimise different interpretations and ensure the safety of residents. (Previous timescale was 01/08/06) All staff who handle food must be provided with training in Basic Food Hygiene to prevent infection and maintain residents in good health. All staff must be provided with training in Moving & Handling to ensure that residents are moved and handled safely and with due regard to potential hazards. All staff must be provided with training in First Aid to ensure that residents receive appropriate treatment following an accident. DS0000002171.V341267.R01.S.doc Timescale for action 01/09/07 2. YA20 13(2) 01/09/07 3. YA35 13(3) 01/11/07 4. YA35 13(5) 01/11/07 5. YA35 13(4) 01/11/07 Larklands And Church View Version 5.2 Page 24 6. YA35 23(4)(d) 7. YA36 18(2) 8. YA39 24(3) 9. YA42 13(4) All staff must be provided with fire safety training at least once a year, and twice a year for those who work night shifts. This is to ensure that staff can maintain residents’ safety in the event of a fire. The company must provide the Manager with regular formal, planned supervision so as to ensure a quality service is being provided to residents. The views of residents’ relatives and others involved in residents’ lives must be periodically sought regarding the quality of service provided. This is to ensure that care provided is continually focussed on their individual needs. Risk assessments of the environment must be carried out and periodically reviewed to ensure the safety of all residents and staff. 01/11/07 01/10/07 01/10/07 01/10/07 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. 3. 4. Refer to Standard YA6 YA6 YA6 YA18 Good Practice Recommendations United Health should be supporting the Home in its use of a ‘person centred’ approach and provide guidance on this subject if necessary. Recorded care planning objectives should underpin the Home’s activities with individual residents so as to facilitate the evaluation of them. Recording systems should provide evidence of the comprehensive reviews of risk assessments. Photographs, or other means, should be considered as a pictorial representation of food - to further enable residents to make choices and decisions about what they eat. (This was a previous recommendation) DS0000002171.V341267.R01.S.doc Version 5.2 Page 25 Larklands And Church View 5. 6. 7. 8. 9. 10. 11. YA19 YA20 YA20 YA32 YA33 YA39 YA39 A risk assessment, relating to the use of bed rails for one resident, should be completed as soon as possible. All nurses at the Home should receive refresher training on the safe use of medicines. The Home’s ‘Administration of Medicines’ policy should include the administration of ‘prn’ medication. (This was a previous recommendation) At least 50 of social care staff should hold a National Vocational Qualification (NVQ) to level 2 or above. The Home should continue to consider ways of reducing the long hours worked by some staff. (This was a previous recommendation) Monthly quality monitoring visits should be made to the Home consistently. The Annual Plan should indicate timescales for achievement and cover a particular period of time. (This was a previous recommendation) Larklands And Church View DS0000002171.V341267.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 Larklands And Church View DS0000002171.V341267.R01.S.doc Version 5.2 Page 27 - 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!