Inspection on 06/02/07 for Leahurst

This inspection was carried out on 6th February 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 4 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 15/08/07

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 Key Unannounced Inspection 6 February 2007 09:30 Leahurst DS0000005193.V324211.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.V324211.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.V324211.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 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.V324211.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 1 January 2006 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, seven care assistants, a catering manager, weekend cook and a domestic assistant. The fees at Leahurst are £360.00 per week. From April 2007 the fees will commence at £369.00. Optional extras include personal items, holidays, activities and hairdressing. Leahurst DS0000005193.V324211.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 6 February 2007 and lasted eight hours. Maureen Brown carried out the visit. 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 some had been met. Four requirements and twelve recommendations were made. The previous requirement had been partly addressed and was reiterated during this visit. 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. The relatives contacted confirmed that they were welcomed into the home and they were satisfied with the overall care provided. Other comments included “My relative is well looked after and I am very pleased with the care provided”, “I have been favourably impressed with the care given” and “The service users are well provided for”. Staff spoken to commented, “I like working here” and “I like to support the service users and feel I make a difference”. One comment card received from a visiting professional stated “we have placed people with very complex needs at Leahurst, and the home with the leadership of the registered manager has been of a very high standard in supporting the individuals to create a better way of life for them, many thanks to all the team”. Leahurst DS0000005193.V324211.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: To ensure that prospective and current service users have up to date information, the statement of purpose and service users guide should be reviewed and updated on an annual basis. Also the home should consider other appropriate formats for the statement of purpose and service users guide to be produced in. Within the care plans the social services reviews should be monitored and copies kept up to date; the homes reviews should be brought up to date; risk assessments should be developed with more detail being included in the assessment and be brought up to date. Also annual healthcare checks should be carried out. The daily records should not be written in red pen. For the protection of the health and welfare of the service users the issues regarding the environment must be addressed. The carpet in dining room, smoking room and corridor downstairs must be deep cleaned or replaced, as necessary and other types of suitable flooring for these areas should be considered. The emergency assistance pull cord in shower room, which is missing must be replaced and the issue of rust on shower rail must be addressed. A plan and implementation of a programme of refurbishment and redecoration should be undertaken. To ensure that residents are protected from abuse, neglect and self-harm the Adult Protection policy and procedure should contain up to date information including the Commissions details. To ensure that staff are properly supervised in their role each staff member must receive regular formal supervision. Annual staff appraisals should be held. To ensure that information regarding complaints is correct, up to date information must be made available including timescales with regard to complaints made and the details of the Commission. To ensure that all views are taken into account with regard to future planning of the home the quality assurance process should include stakeholders views within the process and surveys should be completed annually. For the protection and promotion of health, safety and welfare of the residents the gas safety certificate must be obtained annually. Please contact the provider for advice of actions taken in response to this Leahurst DS0000005193.V324211.R01.S.doc Version 5.2 Page 7 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.V324211.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.V324211.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 adequate. This judgement has been made using available evidence including a visit to this service. Some information is provided for residents to make a decision about moving into the home, however this is not up to date. EVIDENCE: The Statement of Purpose and Function was updated October 2005 and Service Users Guide was revised April 2006. However both documents did not have up to date information detailed, including information regarding the Commission. These documents were written in standard print format. Also available was a leaflet about the home. Staff stated they gave the leaflet to prospective service users. The last inspection report was not readily available. It was suggested that other types of format in line with service users needs be considered for the service users guide and that both documents should be reviewed and updated. 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. Leahurst DS0000005193.V324211.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 adequate. 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. EVIDENCE: Four residents’ care records were seen during this inspection. These were presented in individual folders and a basic format was used. However on discussions 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 some information on personal care. Two of the four files seen had out of date homes reviews. One person didn’t have a care plan or risk assessment completed. This was raised with the manager who stated he was “surprised”. The other person had been reviewed recently. It was suggested that the home should undertake regular client reviews. Leahurst DS0000005193.V324211.R01.S.doc Version 5.2 Page 11 Two of the four files seen had Social Services reviews, however one was over two years old and the other one was in date. Of the other two files one didn’t have a review and the other person had not been at the home long enough to receive an annual review. It was recommended the manager contacts social services and obtains reviews for all service users. Daily records were appropriate and were completed for both day and night shifts. Night shift workers wrote in red ink. It was suggested that this practice cease as it is disconcerting to the reader and difficult to produce a good photocopy from red ink, should this be necessary. However, 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 they are able to make their own day-to-day decisions. They are support by family members and the staff team. One service user had an independent advocate. A very basic general risk assessment was available in each service users file seen except for the new resident. Of the other three all were out of date, reviews being undertaken in 2005 and 2002. It was recommended that all service users have an up to date risk assessment, which is reviewed annually or more frequently as appropriate and that the risk assessment process be developed. Leahurst DS0000005193.V324211.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’ timetable reflects the range of activities undertaken which included doing 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. On discussion with the staff they said that usually twelve to seventeen people go together for meals. It was suggested that smaller groups might be more appropriate, however, staff confirmed that they always went out in large groups and went on the annual holiday all together. Leahurst DS0000005193.V324211.R01.S.doc Version 5.2 Page 13 Two service users are engaged in educational and occupational pursuits. One service user works for the Scope Shop locally, one goes to the local college studying Maths and English. 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. Service users were heard to ask after each other and showed concern for each other. The daily routines appear appropriate. Service users have a timetable and complete household tasks such as meals, shopping, cleaning, washing and ironing. Service users like to listen to CDs, watch TV, Videos and DVDs and go into town. 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. One service user would like to make their own meals each day but at this time they only cook once a week. Today’s lunch was meat and potato pie with vegetables and jelly and cream to follow. Other choices were sandwiches or kippers. Evening meal was beef burger, cheeseburger, onion rings, tomatoes or sandwiches and yoghurt for pudding. Three choices of meals were available at each mealtime and mealtimes were flexible. 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 meals in the main dining room. Leahurst DS0000005193.V324211.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. Storage of medication is appropriate. 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. 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 many cases annual checks with the dentist, optician, and medication reviews had not been completed. It was suggested these be brought up to date. Leahurst DS0000005193.V324211.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. Old medication is returned to the pharmacist. The staff stated that they had a very good relationship with the pharmacist. 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. The home has a homely remedies policy. The manager had difficulty in finding the medication policy and the one produced was an old copy. The manager subsequently faxed a copy of the up to date policy the day following, the visit to the home. Leahurst DS0000005193.V324211.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 adequate. This judgement has been made using available evidence including a visit to this service. Residents and relatives were satisfied with the support they received from the manager and staff. Policies and procedures were in place to ensure that residents were protected from abuse, neglect and self-harm but these were not up to date. EVIDENCE: The complaints procedure was seen and was available to service users. The procedure didn’t contain information regarding timescales in which complaints would be dealt with and details of the Commission. Since the last visit five complaints had been received at the home. It was noted that these had been resolved with the manager’s intervention. A requirement was made regarding this. 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. Within the homes policy, on the procedure of the event of an alleged abuse, the Commissions details are incorrect and a recommendation was made. The home also has policy 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.V324211.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 poor environment for the people to live in. EVIDENCE: A tour of the home was undertaken with a member of staff. The home is divided into the main building, flat and lodge. The main building has twenty bedrooms and the flat and lodge have three bedrooms each. During this visit all the communal areas and a random selection of bedrooms were seen. The home was furnished in a domestic style, which had a “tired and uncared for” appearance. The décor was poor, with discoloured wallpaper and paintwork. 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 Leahurst DS0000005193.V324211.R01.S.doc Version 5.2 Page 18 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. In one bedroom the curtains were held up with only a few curtain hooks, and in another room the bedding was very creased and looked “unkempt”. One bedroom had an en-suite facility. Most service users had their own TV in their bedrooms. Some service users were using their bedrooms during this visit. In the main building areas of concern included: • • • • • In the shower room there was no pull cord for the emergency response unit; In the shower room the pole for shower curtain rusty; In the smoking lounge the carpet badly stained with cigarette burns; The downstairs corridor carpet was very badly stained and worn; and In the dining room the carpet was very badly stained and worn. Requirements were made regarding all these points. There is a patio leading from the smoking lounge 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. Staff stated that they had bar-b-ques in the summer, which the service users enjoyed. The main kitchen was seen and was clean and serviceable. The resident’s kitchen was serviceable but the floor was very “sticky”, something had been spilt. During discussions with the staff it was stated that the residents are supposed to clean up after themselves, however, this obviously had not happened and perhaps the service users needed extra support with this task. 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”. I recommended to him that the home is in urgent need of refurbishment and redecoration. Leahurst DS0000005193.V324211.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 good. This judgement has been made using available evidence including a visit to this service. Service users are protected by the homes recruitment policy and practices as they are consistently followed. 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. Six of ten staff had obtained NVQ level II or III in Care and four staff members were currently undertaking NVQ level II in Care. Each staff member had a video training record sheet. This sheet was signed by the staff and countersigned by the senior when it had been viewed. 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. Leahurst DS0000005193.V324211.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. Staff appraisals had not been completed. A recommendation was made that these be completed on an annual basis. Staff supervision on day-to-day basis was good however formal supervision had lapsed. The homes supervision policy stated that this would be held “every four to six weeks”. A recommendation was made that staff receive formal supervision six times a year with records kept. The last staff meeting was held on 9.1.07 and was attended by 8 staff. Issues discussed included absences, theft, service users, staff and activities. The previous meeting was held on 29.9.06. Leahurst DS0000005193.V324211.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 adequate. This judgement has been made using available evidence including a visit to this service. The health, safety and welfare of the service users would be protected if all safe working practices were in place. When the views of service users are obtained they influence the running of the home, however this is not completed on a regular basis. EVIDENCE: The Registered Manager has worked at the home for fourteen years in a managerial position. 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. Leahurst DS0000005193.V324211.R01.S.doc Version 5.2 Page 22 Quality assurance is completed by residents meetings, individual conversations and satisfaction surveys. The last survey was completed in June 2005. A recommendation was made that these should be completed annually and include other stakeholders views. Other information is gained through discussions with the residents and residents meetings. The last residents meeting was held in October 2006 and 6 residents attended. Issues discussed included meals, heating, days out, behaviour, resident’s kitchen and activities (Service users requested Maths, spelling, exercises and snowdrops for planting). Safe working practices included fire alarm tests, emergency lighting tests and the electrical safety certificate. It was noted that servicing of the nurse call system and fire extinguishers were in place and that the home had a chlorination certificate. Following a previous requirement the Portable Appliance Testing had been carried out in April 2006, however the requirement regarding the Gas safety certificate which was not available remains outstanding and was reiterated. Leahurst DS0000005193.V324211.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 2 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 2 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 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 2 3 X 3 X 2 X X 1 X Leahurst DS0000005193.V324211.R01.S.doc Version 5.2 Page 24 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 YA22 Regulation 22(4) Requirement The registered person must ensure that the complaints procedure contains details of the Commission and timescales of how and when a concern will be dealt with. The registered person must ensure that the carpet in dining room, smoking room and corridor downstairs are deep cleaned or replaced as necessary and to consider other types of suitable flooring for these areas. The registered person must replace the emergency assistance pull cord in shower room where missing and address the issue of rust on shower rail. The registered person must ensure that the gas safety certificate is obtained annually. Not completed by 1.4.06. Timescale for action 30/03/07 2 YA24 23(2)(b) 30/03/07 3 YA24 23(2)(c) 30/03/07 4 YA42 13(4), 23(2)(4) 30/03/07 Leahurst DS0000005193.V324211.R01.S.doc Version 5.2 Page 25 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 ensure that the statement of purpose and service user guide is updated to ensure that all information is correct including the Commissions details. The registered person should consider other appropriate formats for the service users guide in line with the service users needs. The registered person should ensure that care plan reviews are undertaken on a regular basis. The registered person should ensure that Social Services reviews are completed. The registered person should ensure that red pen is avoided on the daily log sheets. The registered person should ensure that risk assessments are reviewed annually or more frequent as necessary. The registered person should ensure further development of the risk assessment document, to fully include all areas of risk. The registered person should ensure that annual healthcare checks are carried out. The registered person should ensure that the Adult Protection policy and procedure contains up to date information including the Commissions details. The registered person should ensure that a plan and implementation programme of refurbishment and redecoration is undertaken. The registered person should ensure that staff receive six formal supervision sessions a year. The registered person should ensure that annual appraisals are undertaken. The registered person should ensure that satisfaction surveys are undertaken annually and that other stakeholders are included in this process. 2 3 4 5 6 7 8 9 10 11 12 13 YA1 YA6 YA6 YA6 YA9 YA9 YA19 YA23 YA24 YA36 YA36 YA39 Leahurst DS0000005193.V324211.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.V324211.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. 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