Inspection on 27/11/06 for Lee Beck Mount

This inspection was carried out on 27th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lee Beck Mount 15/11/07

Lee Beck Mount 26/01/06

Lee Beck Mount 06/09/05

Lee Beck Mount 31/01/05

Lee Beck Mount 29/09/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Lee Beck Mount 108 Leeds Road Lofthouse Wakefield West Yorkshire WF3 3LP Lead Inspector Stevie Allerton Key Unannounced Inspection 27th November 2006 11:00 Lee Beck Mount DS0000001529.V307892.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 Lee Beck Mount DS0000001529.V307892.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. Lee Beck Mount DS0000001529.V307892.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lee Beck Mount Address 108 Leeds Road Lofthouse Wakefield West Yorkshire WF3 3LP 01924 824065 01924 823 787 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) Advitam Limited Mr Richard Smith Mr Neil Robinson Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Lee Beck Mount DS0000001529.V307892.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th January 2006 Brief Description of the Service: Advitam is a Ltd company, which operates one residential care home, Lee Beck Mount. Lee Beck Mount is situated on the A61 in the Lofthouse district of Wakefield. It is a large detached residence originally constructed in 1890 but has undergone extensive refurbishment to provide care for twelve male and female residents with learning disabilities who may also have physical disabilities, including access for wheelchairs. The home does not provide nursing care. Lee Beck Mount is within walking distance of all local amenities; there is a range of public houses and restaurants that are welcoming to the residents of Lee Beck Mount. Leeds and Wakefield City Centres are accessible by public transport. The home has two multi-passenger vehicles, which are used throughout the week. All bedrooms are spacious and provide en-suite facilities. There is a large communal lounge area, a dining room and a kitchen area for residents’ use and a covered patio area outside. Current fees are from £650 to £1,500 per week. Lee Beck Mount DS0000001529.V307892.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out without prior notification and was conducted by one inspector. The inspection took place over one day, starting at 11.00am and finishing at 7.30pm. This was the first visit made by this inspector to the home. One of the Managers, Neil Robinson, was on duty and assisted the inspector throughout, joined by Richard Smith, the other Registered Manager, later on. The inspector would like to thank everyone who took the time to talk and express their views. Survey forms were sent out to a selection of health and social care professionals and one was returned. Easy-read format comment cards were also sent out to the service users and eleven were returned. Before the visit, information about the home was reviewed. This included looking at any notified incidents or accidents and other information passed to CSCI since the last inspection, including reports from other agencies, such as the Fire Officer. This information was used to plan this inspection visit. The inspector case tracked three service users. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. Where appropriate, issues relating to the cultural and diverse needs of residents and staff were considered. Using this method, the inspector assessed all twenty-one key standards from the Care Homes for Younger Adults National Minimum Standards, plus other standards relevant to the visit. The inspector spent time with identified service users and spoke to relevant members of the staff team who provide support to them. Documentation relating to these service users was looked at. Where possible, contact was also made with relatives and external professionals, to obtain their opinions about the quality of services provided at the home. What the service does well: The home has a friendly and welcoming atmosphere. Care is provided in a clean, tidy and well maintained building. There is a low turn over of staff, which means that the staff team know the service users very well. Residents are provided with an extensive and diverse range of day care, leisure activities, day trips and holidays. They have good opportunities for personal development and involvement in the local and wider communities. Lee Beck Mount DS0000001529.V307892.R01.S.doc Version 5.2 Page 6 The management and staff make sure that residents make meaningful decisions about their lives and participate in the daily day-to-day running of the home. The staff promote and encourage all the residents to be as independent as possible and to reach their full potential. The Managers have demonstrated their ability to tackle incidents of poor practice reported to them, as well as complaints. What has improved since the last inspection? What they could do better: The written care plans for the service users could give more information, so that staff all know how to support each person in the best way for them. The staff also need to be able to show that each service user’s needs have been regularly reviewed, with their own views taken into account, and that decisions based on the assessed risk to that person are properly recorded. Many key documents did not have dates included, so it was difficult to decide if the information was current or out of date. Staff still need to receive training in Adult Protection and the home’s Adult Protection policy needs to have a procedure linked with it, so that staff have some written guidance to follow if an incident is reported to them. Record keeping needs some attention, particularly those records linked with health and safety; where the records show that staff have not had fire practice, for example, steps must be taken to address this as soon as possible. Information requested by CSCI on the pre-inspection questionnaire should also trigger action to ensure that certain checks are made, for example, gas and electrical installation checks Lee Beck Mount DS0000001529.V307892.R01.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. Lee Beck Mount DS0000001529.V307892.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 Lee Beck Mount DS0000001529.V307892.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 & 5 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the home. The home’s Statement of Purpose, brochure and philosophy statement give good information about the way of life at the home and the standard of support and facilities it can provide. Service users are assessed to ensure that their needs can be met and are introduced into the home in a way that respects their individual preferences. However, there was no evidence in the case records that service users or their families had been issued with a copy of the contract for care. EVIDENCE: The case records for the last person to be admitted were looked at, and discussions took place with the providers/managers. Service users are admitted at the pace to suit them and their particular circumstances. The daily records gave a picture of a gradual introduction to the home, with accompanied visits followed by unaccompanied visits. There were some good observations and recording, which form the basis of the home’s own assessment of abilities and needs. Each person undergoes a 3 month assessment period before a place is made permanent. Lee Beck Mount DS0000001529.V307892.R01.S.doc Version 5.2 Page 10 Service user comment cards said that they were given information about the home and were able to choose to live there, apart from a small number of people who moved there as an emergency response to their previous home closing down. The parent of one service user was visiting and was asked whether she had a contract setting out what care was to be provided and the cost of this. She said that she hadn’t got a contract and did not know how much it cost to live at the home. Lee Beck Mount DS0000001529.V307892.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to the home. In discussion with the service users and the observations of staff support being provided during the visit, a judgement could be made that care needs are met. However, the written records did not give an up to date picture of everything that was happening for each person, and how staff were to properly support them. EVIDENCE: Three service users were selected for case tracking, their care records looked at in depth and discussions held with them where possible. Other service users’ care plans were also referred to during the site visit. The care plans seen did not always meet the standards for how these records should be kept, (see Schedule 3 of the Care Homes Regulations) nor did they provide evidence of reviews of care taking place at regular intervals. Lee Beck Mount DS0000001529.V307892.R01.S.doc Version 5.2 Page 12 Staff support individual service users well because of their depth of knowledge of each person, the low staff turnover contributing to this. Service users are encouraged and supported to make their own decisions and to be involved in all aspects of the running of the home. Some risk assessments are in place, though most were not dated and it was not clear how current they were. Lee Beck Mount DS0000001529.V307892.R01.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, 14, 15, 16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to the home. Service users lead interesting lives and have the opportunity to be involved in gardening and looking after livestock, as well as the more usual activities and leisure interests within the community. Staff are good at encouraging families and friends to be involved in everyday life. Service users receive a nutritious diet. EVIDENCE: Care plans reflected what service users said in discussion, that there was a range of social and leisure activities available at the home and in the community, which people enjoyed taking part in. Comments made on comment cards, about not having as much choice during the week days refer to the limitations imposed by attendance at Day Services and what is on offer there. One man who was case-tracked spoke about what he liked doing. He knew his key worker’s name and said that he got help with shopping and choosing Lee Beck Mount DS0000001529.V307892.R01.S.doc Version 5.2 Page 14 Christmas presents for the people close to him. He had a new TV and enjoyed watching DVDs (he has an extensive collection) and listening to music in his room. Other service users said they were looking forward to Christmas; some were going out that evening to Leeds Playhouse. The home has two people-carrier vehicles, which enable people to get out and about into the community. There is a published programme of activities, with staff delegated to lead specific sessions; one of the staff was scheduled to do some baking with a small group that evening. Service users and staff have a good rapport between them. There is an easy, relaxed atmosphere in the home. Within the grounds there is a separate portakabin fitted out to provide a good venue for doing craft projects, teaching, or one to one work. Vegetables are grown and the hens provide fresh eggs, all of which are used in the home. The menus appear to be well balanced and use mainly fresh produce. Some service users are able to make their own drinks in the kitchen. The servery area outside the kitchen hatch is not used any more for drinksmaking, so service users unable to make their own have to ask staff to go into the kitchen and do this for them. The use of pump-action vacuum flasks should be considered, as a means of promoting independence in a safer way. Lee Beck Mount DS0000001529.V307892.R01.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): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the home. Service users receive personal and health care support appropriate to their needs, with primary health care professionals giving a service where needed. Medicines management is good; the records for PRN medication is particularly good and provides safeguards for the service users, preventing over-use. EVIDENCE: Care plans largely reflect the personal care and health care input each person requires, although some information appeared to be out of date. In discussion with the staff, there was a sensitivity to the problems of ageing presented by individuals, for example, making sure there is a wheelchair available for a holiday that involves a good deal of walking, so that everyone can be included in all activities. Staff reported a good level of support from GPs and Community Psychiatric Nurses; continence aids are supplied through the local surgery. Medication is well managed and the staff team have good support from the pharmacist who supplies the medicines in a pre-dispensed format. All of the staff have had sufficient training to be deemed competent by the Managers to Lee Beck Mount DS0000001529.V307892.R01.S.doc Version 5.2 Page 16 give medicines. Recording was seen and no anomalies apparent. The use of PRN (“as required”) medication was discussed – for what circumstances it is prescribed, who makes the decision to use it, and how it is recorded. The Managers have developed a better recording system for this, as they felt the previous method of recording was not accurate enough. Service users said they liked the privacy afforded by having their own rooms, with a key if they want one (some do not want this). Friends are able to visit in private. Some relatives that were spoken to said they were very pleased with the home. It had been chosen carefully, following a lot of visits to services all over Yorkshire. They were impressed with the building and its’ setting, the atmosphere and the relationship that has been developed with the staff, who were said to be very supportive without taking over completely from the family. “We feel much more settled ourselves, knowing that … is contented here.” Lee Beck Mount DS0000001529.V307892.R01.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 the home. The Managers have a very open and transparent approach to complaints management, as demonstrated through the recent complaint investigation. This was handled very well and, in the process of examining records for the investigation, has enabled them to identify good staff practice as well as areas for improvement. Adult Protection awareness is good, although the policy in place needs strengthening with a procedure for staff to follow, should an incident take place. Service users’ finances are safeguarded with proper accounting systems. EVIDENCE: Service users said they would tell their key worker or staff at the day centre if they were unhappy about anything. Relatives were asked about their confidence in raising issues of concern. It was clear that channels of communication were good and that they felt comfortable in advocating for their relative should the need arise. The Managers had recently investigated a complaint made by relatives and made the report of the investigation available to the inspector during this visit. This was the first formal complaint the home had received and had been an opportunity to put the complaints procedure into practice; it was responded to within their published timescale and had been resolved to the satisfaction of the complainants. Lee Beck Mount DS0000001529.V307892.R01.S.doc Version 5.2 Page 18 Both Managers have been on Adult Protection training and it is intended that the remaining staff receive their training in January. An Adult Protection policy is in place and has been signed by the staff to say they understand it. It needs to be expanded to include a procedure, outlining what needs to be done if an incident occurs or an allegation is made. Proper systems are in place to manage the finances of those people unable to manage their own. Lee Beck Mount DS0000001529.V307892.R01.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, 25, 28 & 30 Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to the home. The building is equipped and maintained to a high standard, which ensures that service users are kept safe and have a pleasant, homely and comfortable place to live. EVIDENCE: One of the service users who was case tracked showed me his bedroom; a tour of the rest of the building was carried out, accompanied by the Managers. The home is spacious and well laid out, providing sufficient room for different activities to take place at once. All of the bedrooms are en-suite and provide good space for service users to personalise. The home was clean throughout, and protective equipment is available for staff to use. Fixtures and fittings are of high quality and the Managers said that redecoration and renewal was done on a regular basis to keep the standard high. The home meets current fire safety standards. Lee Beck Mount DS0000001529.V307892.R01.S.doc Version 5.2 Page 20 There are two office areas, one main business office that the staff use on a day to day basis, and a quiet office that affords a more private space in which to do supervision, interviews, etc. Outside, the home stands in extensive grounds, some of which are laid to gardens and covered patio space, and some for the growing of vegetables and keeping of poultry. The grounds are managed by a handyman/driver, with service users assisting. There is no smoking allowed in the house, so those who smoke sit out on the covered patio. Service users said they liked the house; one said that he enjoyed being able to watch TV in his own room, which he liked keeping tidy; another preferred mixing in the communal areas and talking with other service users and staff. Lee Beck Mount DS0000001529.V307892.R01.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): 32, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the home. Staff are suitably trained and supported in their work. They have a good level of knowledge about the service users and come across as being very competent and able to promote best practice. Service users and their relatives have good relationships with the staff. EVIDENCE: Five staff members of differing job roles were seen during the visit, as well as the two Managers. Staff were enthusiastic and spoke knowledgably about their work. There is a very low staff turnover, with no new starters since the last inspection. There had been an incident during the summer, which culminated in a staff member being dismissed for gross misconduct (being under the influence of alcohol whilst on duty); this had come to the attention of the Managers through another staff member using the “whistleblowing” procedure. Training has continued, with National Vocational Qualifications (NVQ) levels 2 & 3 being worked towards; it was said that the staff support each other very well with their NVQs. Learning Disability Award Framework (LDAF) is to be considered in the future for new starters. Staff have recently had some Lee Beck Mount DS0000001529.V307892.R01.S.doc Version 5.2 Page 22 training in dealing with challenging behaviour, but Adult Protection training (for all staff, including ancillary staff) will not take place until Jan 2007. Staff meetings are held periodically, although the Managers feel that communication is good on a day to day level. The inspector was able to sit in on shift handover at 3.00pm, the morning shift passing on information to those on duty in the afternoon. Someone is designated as the responsible person on each shift, for keys, medications, and allocating tasks amongst the team. In discussion with the named person for the afternoon shift, she spoke knowledgably about the service users and how potential conflicts between certain individuals is handled. Relatives say they find the staff approachable and find they can work in partnership with them -“They haven’t totally taken over and we still feel involved in making decisions”. Lee Beck Mount DS0000001529.V307892.R01.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, 41 & 42 Quality in this area is adequate. This judgement has been made using available evidence, including a visit to the home. Some records were not available, or showed that some key staff had not received relevant training, therefore it was difficult to assess whether health and safety is being fully promoted. Policies that were seen were written in a way that promotes equality and values diversity. The Managers have responded positively to a complaint made to them and have used it as an opportunity to monitor quality. The Managers work closely with the staff team and are readily available to service users and relatives. EVIDENCE: The Registered Manager is currently in the process of working towards a suitable qualification, which will back up his years of experience. Management Lee Beck Mount DS0000001529.V307892.R01.S.doc Version 5.2 Page 24 tasks are shared between Richard Smith and Neil Robinson, both of whom also work on shift alongside the staff. There are suitable arrangements for on-call support out of normal working hours. A sample of written policies and regulatory records were seen, which included: fire safety records, medication records, service users financial records, complaints, staff rotas, service users’ care plans. Some areas for improvement were identified - night staff need to experience fire drills & practice; maintenance records for gas & electrical installations must be available for inspection; service user care plans must include all of the required information and be reviewed at least every 6 months. House meetings were discussed; two meetings had been held to discuss holidays, but had been found to be unproductive. Suggestions were made as to how these might be moved forward. The Managers have taken the opportunity to use a complaints investigation as a means of monitoring quality in the way that policies are written and records are made. A thorough examination of written records over a long period of time has highlighted some good practice, which has enabled individual staff to receive positive feedback. Lee Beck Mount DS0000001529.V307892.R01.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 X 2 3 3 X 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 4 25 4 26 X 27 X 28 4 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 3 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X 2 2 X Lee Beck Mount DS0000001529.V307892.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement The registered manager must develop and agree with each resident an individual Care Plan, which may include treatment and rehabilitation, describing the services and facilities to be provided by the home. Reviews should be held a minimum of every 6 months or sooner where required. (previously agreed timescale 3/04/05, 16/11/05 and 30/03/06 not fully met). Risk assessments must be undertaken and form part of the care plans (previously agreed timescale of 30/03/06 not fully met). The adult protection policy needs to be expanded, to include a procedure for staff to follow if such an incident is reported. That all staff should receive training in adult protection (previously agreed timescale of 30/03/06 not fully met). The registered manager(s) must complete training to meet the NVQ IV in management. (previously agreed timescale DS0000001529.V307892.R01.S.doc Timescale for action 28/02/07 2. YA9 15 28/02/07 3. YA23 13(6) 28/02/07 4. YA33 18 28/02/07 5. YA37 9 30/06/07 Lee Beck Mount Version 5.2 Page 27 6. 7. YA42 YA42 23(4) 23(2) 3/04/05, 16/11/05 and 30/03/06). All staff, including night workers, must receive fire training and practice at least twice a year. The registered persons must ensure that all mechanical, gas and electrical systems in the home are maintained in a safe condition, and records kept. 30/06/07 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA5 YA16 Good Practice Recommendations Service users and/or their representatives should receive a contract specifying the terms and conditions of occupancy, the facilities provided and the fees charged. Consideration should be given to the use of vacuum flasks in the dining room hatch area, to provide more independence for service users unable to make their own drinks with a kettle. Learning Disability Award Framework training should be considered for new workers. 3. YA35 Lee Beck Mount DS0000001529.V307892.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Lee Beck Mount DS0000001529.V307892.R01.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!