Inspection on 15/02/07 for Laverneo

This inspection was carried out on 15th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Laverneo 06/03/09

Laverneo 25/01/06

Laverneo 12/08/05

Laverneo 24/02/05

Laverneo 04/08/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Laverneo Pennywell Road Nookside Sunderland SR4 9HZ Lead Inspector Elsie Allnutt Key Unannounced Inspection 15th February 2007 10:00 Laverneo DS0000015745.V313525.R02.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 Laverneo DS0000015745.V313525.R02.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. Laverneo DS0000015745.V313525.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Laverneo Address Pennywell Road Nookside Sunderland SR4 9HZ 0191 528 6908 0191 242 1648 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) SCOPE Ms Elaine Douglass Care Home 4 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (1), Physical disability (3) of places Laverneo DS0000015745.V313525.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th January 2006 Brief Description of the Service: Laverneo is a purpose built detached bungalow in the Pennywell area of Sunderland. It is situated in a residential area, close to bus routes and other local amenities. The home is registered to provide four people with learning disabilities, including three who may have physical disabilities and one who may be over 65years old. The staff provide personal care for currently three service users who have a learning disability and all who have some degree of physical disability. The home comprises a lounge, kitchen/dining room, four single bedrooms, two toilets, a bathroom, a shower room and a shower room. An office/sleep in room is provided for staff who share communal areas within the service users. Externally there is an easily accessible garden, parking facilities are available and there is a separate garage. The home has its own transport. The service has developed a Service User Guide that informs prospective service users about the service, the aims and how these are met. A copy of the recent inspection report is available in the home for anyone to read. The fees charged by the home range between £890 and £1067 per week. Laverneo DS0000015745.V313525.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This planned unannounced inspection took 6 hours over one day in February 2007. The views of three service users and six members of staff were sought. Given the different communication needs of the service user their satisfaction of the service was interpreted not only through speech, but the observations of body language, interaction with staff, discussions with staff and the examination of records. This process demonstrated that all were satisfied with the service, including the care and support given by staff. Questionnaires sent to the relatives of the service users confirmed that they were very satisfied with the service delivered at this home. The quality of the living conditions was looked at and the service users’ care files and a sample of the home’s records were examined. What the service does well: As found at previous inspections the lively interaction of staff and service users creates a warm and welcoming atmosphere in this home. The large oval dining table that accommodates both service users and staff together provides a focus where a mixture of serious discussion and light “chatter”, combined with positive humour takes place. Here service users are given appropriate time and support to take part in discussions about the service and any future plans for the service. The rights and equality of the service users, and the equality of opportunity, are positively promoted. One service user stated; “I am asked how I feel about things and when I speak I always know that what I say is listened to, we are always given enough time to think about how we feel.” Care plans are service user led, recorded well, and describe the needs of the service users clearly and accurately. They also contain guidelines for staff to follow in order that any identified risk is addressed and the service user is protected. Service users, with the assistance of staff have developed individual lifestyles determined by their own preferences and choices. Service users openly discussed these during the inspection and demonstrated their individual preferences by describing what they do during the day. This means that service users live independent lives that give them opportunities to make different friends and acquaintances outside of the home. Laverneo DS0000015745.V313525.R02.S.doc Version 5.2 Page 6 Many of the staff have worked at the home since it opened. This means that service users benefit from being supported by people that know them well and who they trust. One service user confirmed this by saying; “I like living here because it is the same staff that I have known for years and I like them and they know me well.” What has improved since the last inspection? What they could do better: The manager has received advice from an Occupational Therapist and the company’s Health and Safety Advisor in relation to the refurbishment of the bathroom. Both advised that a high/low bath fitted with space either side for staff to support service users, would protect service users and staff from possible injury. The manager confirmed that reports from the Occupational Therapist reflecting this have been sent to New Leaf Housing Agency who are responsible for the building. The team leader confirmed at this inspection the date that the new bathroom is to be fitted the week following the inspection. The information in the home’s Statement of Purpose must be reviewed and updated to reflect the changes made in the Company and in relation to the CSCI’s change of address. This will mean that service users or the representatives have access to current information. So that competent and skilled staff are available to support service users, if an emergency arises, they must update their training in relation to first aid. Laverneo DS0000015745.V313525.R02.S.doc Version 5.2 Page 7 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. Laverneo DS0000015745.V313525.R02.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Laverneo DS0000015745.V313525.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of information, that includes the terms and conditions of the service, is available. This enables service users to make a fully informed choice about where they would like to live. The good multidisciplinary preadmission assessments that are in place demonstrate service users’ needs and aspirations and assist the home to make an informed judgement as to whether they can meet these. EVIDENCE: The service has developed a comprehensive Statement of Purpose and Service User Guide that clearly demonstrate the aims and objectives of the service. However the documents need to be brought up to date to reflect the changes made in the Company and the change of address for the area CSCI office. The organisation has comprehensive policies and procedures regarding the admission process. All of the service users’ care files demonstrate that pre admission assessments had taken place by Care Managers and medical professionals, prior to the service users moving into the home. Laverneo DS0000015745.V313525.R02.S.doc Version 5.2 Page 10 There have been no new admissions to the home since it opened, however there is currently a vacancy. The team leader confirmed that new referrals are currently being looked at and stated that care is taken to ensure that the home can fully meet the individual’s needs. She also confirmed that a sensitive, gradual introduction to the home would take place to ensure compatibility with other service users. Regular monitoring and reviews of the service users’ needs are carried out and where needed a multi disciplinary team is involved. Staff confirmed that this allows service users and staff to discuss any changing care needs or individual aspirations, while also having access to professional advice. Individual care files include contracts that determine the terms and conditions of each service’s user stay at the home. They also include the full cost of the fees charged by the home and how they are to be paid. There are clear written agreements between the home and individual service users in relation to the lease of the home’s vehicle, clearly stating the individual costs incurred. They clearly state what the vehicle is to be used for and how the individual is included in that. The records also confirmed that the contract is reviewed 6 monthly. This ensures that the individual service user is aware of their part ownership of the vehicle and the responsibilities they have in relation to this. Laverneo DS0000015745.V313525.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported to make decisions, which at times may include taking risks and to direct their care in the way that they prefer, all of which is recorded in care plans. By being offered different opportunities and experiences and supported to make informed choices, service users are supported to take control of their own lives. EVIDENCE: Each service user has a care plan that is person centred and signed by the service user. The care plan is recorded in a way that is easily understood. It is divided into two sections the first being lead by the service users who describe their needs and say how they prefer them to be met. Another section addresses the goals and how they are to be met. So that the service users have access to and an understanding of the care plans videos have been made to illustrate what has been written in them. This is good practice that enables Laverneo DS0000015745.V313525.R02.S.doc Version 5.2 Page 12 service users to understand and have control over what it is said and written about them. Service users are encouraged and supported to develop as individuals. Staff stated that the recognition of individual likes and dislikes is important. It was evident that service users choose to take part in individual activities including taking different holidays, according to their preferences. Records throughout demonstrate service users preferences, likes and dislikes. The management of risks are an integral part of the care plans. Records confirmed that any risk identified is managed safely to ensure that service users’ rights are promoted and that they are able to enjoy an independent lifestyle. A risk management plan is in place in relation to one service user’s right to be heard when discussing issues about the service and life in the home in general. As a result of this it was noted that the service user is supported and encouraged to take an effective part in discussions around the dining table and guidelines in the care plan ensures staff are consistent in their approach. Service users manage their finances with the support of staff and any limitations in relation to this are recorded following risk assessment. Records of all financial transactions are recorded in service users files and money held is stored in a secure location. Laverneo DS0000015745.V313525.R02.S.doc Version 5.2 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 the following standard(s): 12,13,15,16,17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home encourages service users to take control over their own lives and to develop lifestyles that are valued and based on individual preferences. The service supports service users’ rights and successfully supports them in maintaining relationships with family and friends. The food is of good quality and sufficient to meet the dietary needs of service users. EVIDENCE: Observations during this and previous inspections demonstrate that many of the homes daily issues and decisions are discussed and solved around the home’s dining table. Here service users are actively encouraged to take part in discussions and make decisions about how the service is run and can be improved. Laverneo DS0000015745.V313525.R02.S.doc Version 5.2 Page 14 Staff stated that this process has developed over a period of time and has resulted in the development of individual service user’s confidence and skills, equipping them to make their own choices and decisions. Even though the dining area is not currently in use due to refurbishment, the dining table has been moved into the lounge where this important activity can continue. Service users and staff confirmed their appreciation of this. Service users enthusiastically discussed the individual lifestyles that they enjoy. One person described the decoupage class that they attend based at the local neighbourhood centre and demonstrated other craft items that they had made, some of which are now used to decorate different parts of the home. Staff support the service user to attend the classes. The member of staff also confirmed that the service user is now a valued member of the class and that new friends had been made. On the day of the inspection another service user attended an activity at a local community centre, while another was supported to attend an a health appointment and later a hairdressing appointment at a local hairdressers. It is noted that such individual lifestyles is the result of an appropriate number of staff available to give 1:1 support. All service users confirmed that they were happy with the lifestyles. Activity plans for the week and the responses they individually have to different experiences are clearly recorded. This good practice enables staff to monitor whether individual choices are successful and to ensure that individual preferences are being met. One service user discussed how they enjoy visiting a family member and how staff support them to do this. Visits by relatives and friends were openly discussed and it was evident when reading records that staff support service users to maintain contact with family and friends, as well as recognising that service users have the right to access and enjoy new experiences where new friendships can develop. A light lunch was taken at the dining table with a group of service users and staff during which time discussions took place. This was a pleasant experience where nutritious food that service users had chosen prior to the meal, was served. Laverneo DS0000015745.V313525.R02.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users personal and healthcare needs are met in a flexible but consistent manner, reflecting their preferences. Medication arrangements are appropriate to the needs of service users and are managed in a safe way, ensuring that the welfare of service users is safeguarded. EVIDENCE: Service users are supported to register and attend healthcare practices in the local community. Visits to the GP, dentist’s opticians and other health professionals are recorded in individual care files with the outcome of the visit. Service users’ physical and emotional needs are clearly recorded in individual care plans and positive efforts are made to address service users’ changing needs. This is reflected in the support staff gave to one service who was ill in hospital and later died. While in hospital staff ensured that there was someone from the home there to give guidance and emotional support at all times. There is relevant information in another care plan in relation to one service user, who is now responding more positively to the guidance of staff in relation Laverneo DS0000015745.V313525.R02.S.doc Version 5.2 Page 16 to occasional challenging behaviours. This is recorded clearly and in enough detail to demonstrate that a consistent approach has lead to improved outcomes. The service user was aware of the care plan and confirmed that a positive outcome had been achieved and was able to discuss the process involved. Another care plan confirmed that specialist advice is sought. A Speech and Language report identified special needs in relation to the way drinks and food are to be served for one service user. Guidance and reports in the care plan confirmed that staff follow the advice given and that the service user benefits from this intervention. The home has robust policies and procedures, in relation in relation to the administration of medication. Medication is stored securely in a locked safe and it is administered following safe procedures. Staff were observed checking medication and records prior to administering the medication to individual service users. The records were completed appropriately. Staff confirmed that they have attended training relating to the safe practices in the administration of medication. Laverneo DS0000015745.V313525.R02.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. 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. Appropriate arrangements are in place that protect service users from abuse and seriously addresses complaints and concerns about the service. EVIDENCE: Staff have received awareness training regarding abuse and adult protection, as well as training in relation to handling verbal and aggressive behaviour. Staff were able to appropriately describe what action to take in a situation where they witnessed abuse or an allegation of abuse was reported to them. A senior member of staff confirmed that staff have received training in relation to the local authority’s POVA (Protection of Vulnerable Adults) procedures, a copy of which is available within the home. The home receives letters detailing compliments about the staff and the care practices in the home. One letter received from a senior officer in the local council and from family members, commended staff for their sensitive care and support given to service users and family members during a sad occasion. Entries in the Complaints Book confirmed that complaints and concerns are taken seriously, recorded and satisfactorily addressed. There have been no complaints or POVA issues recorded since the last inspection. The complaints procedures are in picture format and all service users were aware of it and to whom to speak if they are unhappy about something. Laverneo DS0000015745.V313525.R02.S.doc Version 5.2 Page 18 Staff stated that many everyday concerns are addressed effectively when discussing issues around the table and as a result do not grow into major issues. Service users confirmed this and one said: “ If I have a problem I usually discuss it with staff and they listen and it works out.” There are satisfactory procedures used in the home that protect the service users from financial abuse. Each service user has an individual current account and a locked tin to keep their money in. There are individual balance sheets and every transaction is recorded. Two signatures are required for each transaction and the ‘tins’ are audited every week by management. Laverneo DS0000015745.V313525.R02.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,28,27,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment is good and continues to be improved, providing service users with an attractive and homely place to live. The home is homely, comfortable, and clean and provides service users with adequate and accessible private and communal space in which to live. EVIDENCE: The home was specifically built for the current service users needs in 1992. However since this time service users needs have changed and the need to refurbish both the kitchen and the bathroom to accommodate this was identified at previous inspections. A Maintenance Development Plan for 2007 is in place in the home and this clearly identifies the areas of the home that need to be altered. Currently the kitchen is in the process of being refurbished. New kitchen units and appliances have been fitted and new flooring has been put down. This area still needs to be decorated and some electric and plumbing work is in Laverneo DS0000015745.V313525.R02.S.doc Version 5.2 Page 20 need of completion. The dining room area that leads from the kitchen is out of use and awaiting decoration and new flooring to be laid. It is noted that the service users physical needs were taken into consideration when the kitchen was designed. The hob and sink are designed so that they can lower to different heights, to accommodate people who use a wheelchair and there is a small bench that pulls out to provide a lower working area. There is now more space in the kitchen/dining area giving service users more space to independently manoeuvre their wheelchairs, while at the same time gives a more open appearance to this area has been created. Service users and staff are pleased with the improvements so far, but feel that until it is completely finished and everything is fully working, the full effect cannot be appreciated. Considering the amount of structural work carried out during this process, staff have worked hard to ensure that the inconvenience to service users is minimal. There are plans for service users and staff to move out of the house and to stay in a holiday cottage in Northumberland during this month, so that the bathroom can be refurbished. This is so the bathroom facilities can be reorganised and replaced to accommodate service users current needs and to provide a safer environment for both service users and staff. Service users and staff spoke with enthusiasm about this stage of the refurbishment plans. Although such refurbishment is taking place a clean fresh and comfortable environment that reflects good cleaning routines has been maintained. Staff have attended training in relation to infection control and that they follow appropriate guidance regarding the home’s infection control policy. Laverneo DS0000015745.V313525.R02.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Robust recruitment & selection procedures and regular training opportunities ensure that service users are appropriately supported and protected by a competent and qualified staff team. EVIDENCE: This home employs good staffing ratios, the result being that service users’ personal and emotional needs and daily lives are appropriately supported and encouraged. Although there are times when two staff are on duty, such times are short. Generally there are three staff on duty. When service users are engaged in activity this is accommodated on a 1:1 basis. Staff use their hours flexibly to accommodate activities that service users have chosen to take part in, for example on the day of the inspection one member of staff who usually works 2-4pm came into the home at 11am to support a service user with a requested activity. Laverneo DS0000015745.V313525.R02.S.doc Version 5.2 Page 22 There has been very little change of staff since the home opened. Service users therefore benefit from a consistent staff team. Robust recruitment procedures are followed. The examination of the personal file of relatively new member of staff showed that all of the appropriate records were in place, including a completed application form, 2 appropriate references and a satisfactory CRB (Criminal Records Bureau) check. The home has a training budget and training and development plan to ensure the staff maintain and develop skills to meet the needs of the service users. All staff have individual training and development plans and at least five days paid training each year. Training covers issues relating to the needs of the service users for example safe working practices, cerebral palsy disability, diabetes and challenging behaviour as well as mandatory training. However it was noted that staff are currently ready to update their first aid training. The team leader confirmed that this is to be arranged for the near future. Staff confirmed that their training needs are addressed and that they all now have NVQ 2. In addition to this 50 of the staff team have NVQ 3 or above. Staff were proud to confirm that this home is the first service in the Company (Scope) to achieve 100 staff qualified in NVQ. This is commended. It was noted that staff work as a close team and support and respect each others roles and commitments. This was confirmed when staff described how they had supported each other, as well as supporting service users, during a particularly sad and stressful time after the sudden death of one of the service users. Laverneo DS0000015745.V313525.R02.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager, who is well supported by her team leader and staff team, provides good leadership and runs a service that has effective monitoring systems that are focussed on the best interests of the service users. EVIDENCE: The registered manager of this service was unavailable at the time of the inspection, however the team leader competently accommodated the inspection process and demonstrated her awareness of all the management aspects of the home. The manager of this service is a fully qualified registered manager. She has achieved the Registered Manager’s Award and NVQ4 in Care. The team leader states that she is up to date with mandatory training and attends training courses in relation to her role. Recent training includes issues surrounding; budget planning and quality monitoring. Laverneo DS0000015745.V313525.R02.S.doc Version 5.2 Page 24 Staff and service users felt that the manager ensured that everyone is involved in decision-making in the home and that their views and opinions were valued. They confirmed that they all meet with the manager and discuss issues relating to the every the day running of the home, as well as the development of the service. Records of staff and service user meetings confirmed this. It was evident when reading through records that there are good administration systems in place. Personal records of staff and service users are safely kept in locked filing cabinets. Staff confirmed that they are aware of the home’s policies and procedures, which they sign to confirm that they have read them. An effective quality assurance system is in place. There is a monthly monitoring system that covers all aspects of the service delivered, as well as service users views, the outcomes of which are included in the Annual Development Plan that is used as a guidance to improve the service. The next review of the plan is recorded to take place in 2008. Laverneo DS0000015745.V313525.R02.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 2 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 4 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 4 X 3 X X 2 X Laverneo DS0000015745.V313525.R02.S.doc Version 5.2 Page 26 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 YA1 Regulation 6 (a)(b) Requirement The registered manager must ensure that the Statement of Purpose and the Service User Guide are updated to reflect the changes made in the Company and the relocation of the regional CSCI office. The registered manager must ensure that all staff have their first aid training updated as planned. The registered manager must ensure that the bathroom is redecorated and refurbished to meet the service users assessed needs. (Timescale of 01/01/05 & 30/03/06 not met.) Timescale for action 31/03/07 2 YA42 12(1)(a) 13(4) 31/03/07 3 YA27 23 31/03/07 Laverneo DS0000015745.V313525.R02.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA30 Good Practice Recommendations It is recommended that the laundry is refurbished to include wall coverings that are easy to clean. Laverneo DS0000015745.V313525.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South of Tyne Area Office St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Laverneo DS0000015745.V313525.R02.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!