Inspection on 15/08/07 for Leahurst

This inspection was carried out on 15th August 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Leahurst 18/11/09

Leahurst 09/09/09

Leahurst 06/02/07

Leahurst 01/01/06

Leahurst 25/08/05

Leahurst 12/01/05

Leahurst 07/09/04

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

CARE HOME ADULTS 18-65 Leahurst Coronation Drive Widnes Cheshire WA8 8AZ Lead Inspector Maureen Brown Unannounced Inspection 15th August 2007 09:05 15/08/07 9:05 Leahurst DS0000005193.V342700.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 Leahurst DS0000005193.V342700.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. Leahurst DS0000005193.V342700.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Leahurst Address Coronation Drive Widnes Cheshire WA8 8AZ 0151 495 1919 0151 423 3513 hrhleahurst@aol.com 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) Hilton Residential Homes Limited Mr Michael Moran Care Home 26 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (26), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (26), Physical disability (1) Leahurst DS0000005193.V342700.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The total number of Service Users must not exceed 26 26 of the Service Users may be MD 26 of the Service Users may be MD(E) 1 of the MD Service Users may also be PD Date of last inspection 6th February 2007 Brief Description of the Service: Leahurst provides personal care for twenty-six adults with enduring mental health needs. The home has two double bedrooms but uses these for single occupancy. There are two buildings, the main building with a first floor independent three bedroom flat and the lodge a three bedroom detached property. The flat and the lodge have their own kitchen, bathroom and living areas. The main building has twenty bedrooms one of which is en-suite. Other facilities include a resident’s kitchen, dining room, main lounge, conservatory and smoking lounge. The home has a patio area to the rear of the property with a large area of lawn, where service users can sit. There is car-parking area at the front of the property. The home is close to local shops and a mile away from Widnes town centre. It is on a local bus route and close to two railway stations. The staff team consists of the registered manager who is supported by two senior support workers, nine care assistants, a catering manager and a domestic assistant. The fees at Leahurst are £369.00 per week. Optional extras include personal items, holidays, activities and hairdressing. Leahurst DS0000005193.V342700.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit took place on 15 August 2007 and lasted eight hours. Feedback was carried out at the end of the visit with the registered manager. This visit was just one part of the inspection. Before the visit the home was also asked to complete a questionnaire to provide up to date information about them. Questionnaires were also made available for service users, relatives, staff and other professionals to find out their views. Other information since the last key inspection was also reviewed. During the visit various records were looked at and a tour of the home was undertaken. A number of service users and staff were also spoken with and they gave their views about the service. All the key standards were assessed and most had been met. Two requirements and eight recommendations were made. The previous four requirements made had been addressed. Residents commented, “I am happy and value the staff team”, “The staff always treat me well”, “The home is always clean and the carer’s listen and act on what I say” and “The staff are very good and very kind”. Relatives commented through surveys “They provide a “home” in the best way. My relative is at their happiest there than anywhere they have lived in the past” and “I am very happy with the support offered to my daughter and I am glad she had got somewhere good to live.” Healthcare professionals commented, “Very impressed with the care provided”, “Staff have always been considerate to myself when liaising with them regarding reviews”, “The individual’s healthcare needs are usually met by the home” and “The home is good at respecting individuals and meeting their health needs.” What the service does well: The home had an established staff team who were keen for care standards to be maintained. Residents’ plans of care and individual case notes reflected resident’s needs. The staff managed daily activities and entertainments and provided a choice of activities for service users to undertake. Leahurst DS0000005193.V342700.R01.S.doc Version 5.2 Page 6 Relatives confirmed that they were welcomed into the home and they were satisfied with the overall care provided. One relative commented “She was very happy with the support offered to her relative and was glad they had got somewhere good to live.” Staff spoken to commented, “I like working here” and “the staff team was good and that the staff worked well with service users.” Visiting professionals stated “The home always responds to the different needs of the individual”, “Staff have always been considerate to myself when liaising with them regarding reviews, service users assessments of activities of living, and working with the service user to enable them to report from such assessments on their progress” and “The service user always states they are happy and seems to value the input from the staff team.” What has improved since the last inspection? To ensure that prospective and current service users have up to date information, the statement of purpose and service users guide has been reviewed and updated. Within the care plans the social services reviews are being monitored and copies kept up to date. The homes reviews have been brought up to date and risk assessments have been developed with more detail being included in the assessment and these are now up to date. For the protection of the health and welfare of the service users the issues raised regarding the environment have been addressed. The carpet in dining room and corridors has been deep cleaned. The carpet in the smoking room has been replaced. The emergency assistance pull cord in shower room, which was missing has been replaced and the issue of rust on shower rail has been addressed. To ensure that residents are protected from abuse, neglect and self-harm the Adult Protection policy and procedure has been developed to contain up to date information including the Commissions details. To ensure that staff are properly supervised in their role each staff member has started to receive formal supervision. To ensure that information regarding complaints is correct, up to date information has been made available. For the protection and promotion of health, safety and welfare of the residents the gas safety certificate has been obtained. Leahurst DS0000005193.V342700.R01.S.doc Version 5.2 Page 7 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 be made available in other formats on request. Leahurst DS0000005193.V342700.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Leahurst DS0000005193.V342700.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient information is provided for service users so that they are able to make a decision about moving into the home. EVIDENCE: The Statement of Purpose and Function was updated in March 2007 and the Service Users Guide was revised in February 2007, following a previous recommendation. Both documents have up to date information detailed, including information regarding the Commission. These documents were written in standard print format and contained all the necessary information for prospective service users to decide if they wished to stay at the home. Also available was a leaflet about the home. The last inspection report was available. It was recommended that other types of format in line with service users needs be considered for the service users guide. The care needs assessment form was called the daily living and needs assessment form. These were seen in service users files. It contained all the information required to ensure that the home can meet service users needs. Included was information on Next Of Kin, GP’s, personal support and care needs, mental health, medical information and personal history. Each service users file seen contained a pre assessment document. Leahurst DS0000005193.V342700.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ health, personal and social care needs are met by the staff team who enable them to maintain their privacy and dignity. EVIDENCE: Four residents’ care records were seen during this inspection. These were presented in individual folders and these had improved since the last visit. On discussion with the staff team they were able to identify service users specific needs and had addressed these appropriately. Each file contained personal information, risk assessments and information on personal care. All of the files had up to date reviews following a previous recommendation and a further recommendation was made for this process to be continued. Progress had been made with reviews undertaken by Social Services. Three of the four files seen had Social Services reviews and a further recommendation was made that this process should continue. Leahurst DS0000005193.V342700.R01.S.doc Version 5.2 Page 11 Daily records were appropriate and were completed for both day and night shifts. Night shift workers wrote in red ink. A previous recommendation was made regarding the use of red ink, however, the manager stated that this was usual practice and it was easier to identify the night reports if a different colour was used. On further discussion it was agreed that this would be changed to green in future. The records were well-written, easy to follow and were signed by carers. From information received in surveys from relatives and from discussions with service users and staff at the time of the visit, it appears service users are able to make their own day-to-day decisions. Family members and the staff team as necessary support them. Progress had been made with the risk assessments following previous recommendations and these had been brought up to date and further information had been added to these documents including moving and handling, falls and mental health issues. All reviews had taken place over the last three months. Leahurst DS0000005193.V342700.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Residents’ were able to take part in a range of activities. Personal and family relationships were encouraged by the home and the staff team supported people with this. EVIDENCE: The residents’ daily routines appear appropriate, their timetables reflect the range of activities undertaken which included being involved in chores around the home, cooking their own meals, going for meals out, shopping and visiting other local attractions. Residents spoken to said they enjoy going out and about in the community, to local shops and out for lunch with the staff. Recently group of fourteen residents went on holiday to Wales together. Some residents prefer not to go on day trips or holidays. One service user works for the Scope Shop locally, which they enjoy doing. Leahurst DS0000005193.V342700.R01.S.doc Version 5.2 Page 13 Relationships are developed as per individual preference. It was noted that family and friends are welcome at the home and are actively encouraged by the staff and manager to visit. Relationships within the home seem to be good. Daily routines appear appropriate. Visits from family and friends were recorded in the daily record sheets and residents shared with the inspector the contact they had with family members and said they could choose to see visitors within their own room or in the lounges, conservatory or dining area. Visitors were welcome at any reasonable time during the day and no visiting restrictions were in place. The home provides a hand written four-week menu. A variety of meats, cheese, fish were included. Service users can cook their own meal in their own kitchen with staff support. Records are kept when this facility is used. Today’s lunch was corned beef hash or sandwiches, fruit pie and custard. Evening meal also had a choice of meals offered. The service users have three choices of meals at each mealtime and also have flexible meal times and snacks available in between meals. Service users can use their own kitchen to make drinks and snacks as they desire. Service users confirmed that they tend to meet in the dining room for meals and that mealtimes were flexible. The people living in the flat and the lodge have all their meals in the main dining room. Leahurst DS0000005193.V342700.R01.S.doc Version 5.2 Page 14 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 residents’ health, personal and social care needs are met by the staff team who enable them to maintain their privacy and dignity. EVIDENCE: Within the care plan descriptions of how the residents preferred to be supported in their daily routines were documented. Personal care and support are provided in service user own room or bathroom. Most service users require prompting rather that specific care needs support. All residents were dressed differently according to their own choice. Healthcare needs were documented in the care plan files and it was noted that some improvements in this area had been made. All service users had seen their GP or district nurse within the last year and the chiropodist visited on a regular basis. Other visits to the dentist, physiotherapist, optician and continence nurse were recorded. It was noted that in some cases annual checks with the dentist, optician and medication reviews had not been completed. It was recommended that improvements in this area be continued and all annual reviews be brought up to date. Leahurst DS0000005193.V342700.R01.S.doc Version 5.2 Page 15 The medication system was seen. Medication Administration Record sheets were appropriately completed. The medication is in a monitored dosage system provided by the local chemist. It is locked in a cabinet secured to the wall in the small office. The medication was seen administered at lunchtime. Two members of staff complete the medication process. Service users came to the office for their medication. The staff stated that they would take medication to service users if they were unable to come to the office. Staff had received training in “a safe handling of medication” course. This involves a course workbook to go through and a video to watch. The home has medication and homely remedies policies. Controlled drugs medication was seen stored and administered appropriately. This was checked and found to be in order. GP’s commented, “The home is good at looking after the clients”, “The home always responds to the different needs of the individual” and “I am satisfied with the overall care provided.” Leahurst DS0000005193.V342700.R01.S.doc Version 5.2 Page 16 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. Policies and procedures were in place to ensure that residents were protected from abuse, neglect and self-harm and staff are trained in the Protection of Vulnerable Adults. EVIDENCE: Following a previous requirement the complaints procedure had been updated and now contained information regarding timescales in which complaints would be dealt with and details of the Commission. Since the last visit one complaint had been received at the home. It was noted that this had been resolved with the manager’s intervention. The Commission had not received any complaints about the home. The home had Halton Borough Councils’ local authority “no secrets” policy available and the manager confirmed that they would follow these guidelines in the event of an alleged or suspected case of abuse. Staff have viewed the abuse video and would report any case of suspected or actual abuse occurring. The home also has policies on the procedure in the event of an alleged abuse and on physical aggression. Staff spoken with confirmed that they had an understanding of the potential indicators of abuse and what to do if they became aware of an allegation of abuse. Leahurst DS0000005193.V342700.R01.S.doc Version 5.2 Page 17 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 adequate. This judgement has been made using available evidence including a visit to this service. The home provides a clean but inferior environment for the people to live in. EVIDENCE: A tour of the home was undertaken with the manager. The home is divided into the main building, flat and lodge. During this visit all the communal areas and a random selection of bedrooms were seen. From the previous requirement the following improvements had been made. These included a new pull cord for the emergency response unit in the shower room, rust attended to on the shower curtain pole, new carpet in the smoking lounge and the downstairs corridor and dining room carpets had been deep cleaned. All these had improved the environment in which service users were living. Other areas of improvements included the smoking lounge, the lounge in the flat and three bedrooms had been redecorated. New televisions had been provided in the lounges and portable air conditioning units and fans had been provided for use during the warmer weather. Leahurst DS0000005193.V342700.R01.S.doc Version 5.2 Page 18 However overall the home generally had a “tired” appearance. The décor generally remains poor, with discoloured wallpaper and paintwork. Most of the bedrooms seen reflected the décor throughout the rest of the home. Personal possessions were in evidence in the bedrooms. Furnishings in bedrooms were maintained to a poor standard, doors not fitting properly on wardrobes and veneer missing on chest of drawers and wardrobes making these look “shabby”. In bedrooms where service users had provided their own furniture this was of a substantially better quality and condition, but service users should not have to purchase their own furniture to enable them to have acceptable furnishings. Bedding and curtains were in a poor state of repair. Most service users had their own TV in their bedrooms. Some service users were using their bedrooms during this visit. There is a patio leading from either the smoking lounge or the conservatory and a large grassed area to the rear of the home, which was neat and tidy. It is accessible to all the residents. Car parking is available at the front of the building. During the tour it was noted that the home was clean and odour free and the cleaner works hard to keep it up to date. I discussed with the manager if a plan of maintenance /refurbishment or redecoration was available. He stated that there was no plan. Décor and refurbishment is completed “as and when needed”. A previous recommendation regarding this had not been address and it was reiterated. The main kitchen was seen and was clean and serviceable. All records were up to date and fridge, freezer and hot food temperatures were taken daily. This was seen as a measure of good practice on behalf of the cook. Leahurst DS0000005193.V342700.R01.S.doc Version 5.2 Page 19 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 & 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Maintaining the improvements in staff supervision is necessary to ensure wellsupported staff support service users. Service users are protected by the homes recruitment policy and practices ensuring service users safety. EVIDENCE: At the time of this inspection the agreed staffing levels were met. The manager, senior care assistant, two care staff, a cook and the cleaner were on duty. Seven out of eleven staff had obtained NVQ level II or III in Care and four staff members were currently undertaking NVQ level II in Care. There were videos available on abuse in the care home, fire prevention, schizophrenia, epilepsy, depression and anxiety. Staff had also undertaken food hygiene, first aid, moving and handling and medication training. A good range of mandatory and specialist training was available. It was noted that some of the mandatory courses staff had undertaken were a number of years ago. It was recommended that refresher training be considered. Leahurst DS0000005193.V342700.R01.S.doc Version 5.2 Page 20 The recruitment procedure followed ensured that all the staff employed were suitable to work with vulnerable people. Three staff files were examined and these showed that all pre-employment checks had been carried out. Amongst the documentation available were application forms, terms and conditions of employment, job descriptions, General Social Care Councils code of conduct and Criminal Record Bureau checks. Copies of certificates of courses undertaken were also available. The files were up to date and well presented. The last staff meeting was held on 10.8.07 and was attended by ten staff. Issues discussed included timekeeping, cleaning, resident’s holidays and outings, meals and supervision. The previous meeting was held on 23.3.07. Progress had been made on supervision sessions and three out of eleven staff had received their first session. The homes supervision policy stated that this would be held “every four to six weeks”. A requirement was made regarding regular supervision sessions and also a requirement was made for appraisals to be undertaken annually. Previous recommendations regarding supervisions and appraisals had not been fully addressed. Leahurst DS0000005193.V342700.R01.S.doc Version 5.2 Page 21 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 good. This judgement has been made using available evidence including a visit to this service. People who use the service live in a home where their health, safety and welfare are protected. The views of people who use the service are obtained and used to influence the running of the home. EVIDENCE: The Registered Manager has worked at the home for fourteen years in the position of manager. Prior to this the manager trained as a registered nurse in mental health illness. He also has twenty-four years experience of mental health nursing. He has NVQ level IV Registered Managers Award and is an NVQ assessor. Quality assurance is completed by residents meetings, individual conversations and satisfaction surveys. The surveys were completed in June 2007. Comments from surveys included “staff are very kind”, “lovely home”, “ lovely Leahurst DS0000005193.V342700.R01.S.doc Version 5.2 Page 22 meals” and “staff do a splendid job”. The manager stated he was currently developing a survey to be used with other stakeholders and it was recommended this continue and it was also recommended that an analysis of the information gathered be developed and shared with all interested parties. The last residents meeting was held in June 2007 and the previous meeting was held in March 2007 with the minutes available. Areas discussed included meals, medication, care plans and activities. Safe working practices included fire alarm tests, emergency lighting tests, Portable Appliance Testing and the electrical safety certificate. Also regular servicing of the nurse call system and fire extinguishers were in place. Following a previous requirement the Gas safety certificate had been obtained. Policies were available on moving and handling, health and safety, infection control and COSHH. Leahurst DS0000005193.V342700.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 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 2 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 2 36 2 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 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 2 X X 3 X Leahurst DS0000005193.V342700.R01.S.doc Version 5.2 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA36 Regulation 18 Requirement Timescale for action 30/12/07 2 YA36 18 The registered person must ensure that staff receive regular supervision sessions with records kept so that well-supervised staff support service users. The registered person must 30/12/07 ensure that staff receive annual appraisals with records kept so that well-supervised staff support service users. 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 YA1 Good Practice Recommendations The registered person should consider other appropriate formats for the service users guide in line with the service users needs so that people have access to the information in a format that is suited to their particular needs. The registered person should ensure that care plan reviews are undertaken on a regular basis so that up to date information is available to the staff team. The registered person should ensure that Social Services reviews are completed so that up to date information is DS0000005193.V342700.R01.S.doc Version 5.2 Page 25 2 3 YA6 YA6 Leahurst 4 YA19 5 YA24 6 7 YA35 YA39 8 YA39 available to the staff team. The registered person should ensure that annual healthcare checks are carried out so that up to date information is available to the staff team and other professionals. The registered person should ensure that a plan and implementation programme of refurbishment and redecoration is undertaken to ensure that the environment is improved for the service users. The registered person should consider refresher training for mandatory courses to ensure that well-trained staff support service users. The registered person should ensure that satisfaction surveys for other stakeholders are continued to be developed and circulated to stakeholders to ensure a rounded view of the home is obtained. The registered person should ensure that an analysis of the quality assurance system is produced and circulated to all interested parties to show all interested parties have been included in the quality assurance process and their views taken into account. Leahurst DS0000005193.V342700.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 Leahurst DS0000005193.V342700.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. 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