Inspection on 21/07/06 for Lee Court - Leonard Cheshire Disability

This inspection was carried out on 21st July 2006.

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

Other inspections for this house

Lee Court - Leonard Cheshire... 20/09/07

Lee Court - Leonard Cheshire... 06/02/06

Lee Court - Leonard Cheshire... 28/06/05

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Lee Court Queen Street Wellington Telford Shropshire TF1 1EH Lead Inspector Sue Woods Key Unannounced Inspection 21st July 2006 02:00 Lee Court DS0000064235.V305667.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 Court DS0000064235.V305667.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 Court DS0000064235.V305667.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lee Court Address Queen Street Wellington Telford Shropshire TF1 1EH 01952 272020 01952 272050 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) Leonard Cheshire Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Lee Court DS0000064235.V305667.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate up to 5 persons with a Learning Disability who can be either up to the age of 65, or over 65 years of age. 6th February 2006 Date of last inspection Brief Description of the Service: Lee Court is registered with the Commission for Social Care Inspection (CSCI) to provide accommodation and short-term care for a maximum of five adults with a learning disability at any one time. The home currently provides a service for 40 people. Referrals are made through the Joint Community Learning Disability Team based at Tan Bank, Wellington, Telford. The property is purpose built and comprises a lounge, kitchen/diner, 5 bedrooms a bathroom and level access shower room. The service provider is Leonard Cheshire Foundation and was registered with the CSCI in April 2005. The Responsible Individual is Mr Michael OLeary and the manager of the home is Ms Dorothy Neill. Lee Court is situated in Queen Street near the centre of Wellington, Telford and is in walking distance of local amenities and just a short journey away from Telford Shopping Centre. Leonard Cheshires mission statement is included in the homes Statement of Purpose and states To work with disabled people throughout the world, regardless of their colour, race or creed, by providing the environment necessary for each individuals physical, mental and spiritual wellbeing. Consultation with service users is largely informal with the organisation making efforts to implement a questionnaire to review quality following each visit. Current service user contributions towards the service range from £57.50 to £75.40. Lee Court DS0000064235.V305667.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of Lee Court was unannounced but with a days notice in order to ensure that the manager would be available on the day. The inspection commenced at 2pm on 21st July 2006 and concluded at 5.30pm with a second visit to review staffing files on 24th July between 10.00 am and 12.00 pm. The inspection reviewed all 22 key standards and information to produce this report was gathered from the findings on the day and also by review of information received by CSCI prior to the inspection date. A quality rating based on each outcome area for service users has been identified. These ratings are described as excellent/good/adequate or poor based on findings of the inspection activity. The inspection included discussions with the manager and two staff on duty at the time of the inspection and discussions with the two service users staying at the home at the time of the visit. The inspector also spoke with a family member of a guest. A review of care plans and other documentation, as detailed throughout this report, also took place. The manager and staff on duty co-operated fully throughout the inspection. The home has received one complaint since the time of the last inspection. No complaints have been received by Commission for Social Care Inspection. Service users visiting Lee Court prefer to be referred to as guests and therefore this terminology will be used in this report. What the service does well: The home supports an environment where guests visit to relax while having a short break. The home runs very much ‘like a hotel’. Service users are able to continue with their usual daily routines and day services while at Lee Court and arrangements are also made for them to also access their social and leisure activities in the evenings if they wish to do so. Staff are kind and well liked by service users. There is a good team spirit and this enables the team to approach new challenges with a positive attitude. The menus seen during the inspection appeared well balanced and offered choice. Lee Court DS0000064235.V305667.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Individual support plans are still not containing essential information as identified by the organisation. Risk assessments for supporting individuals to take risks as part of an independent lifestyle need to be implemented as per the care and support plans in order to safeguard service users. Record keeping systems are still in need of significant improvement in order to comply with the organisations own policies and procedures. It is of concern that requirements made at the time of the last inspection of the home in relation to risk assessment and care planning remain outstanding and immediate requirements left at the end of the inspection and the subsequent phone call to the responsible individual reflect the Commissions concern. Lee Court DS0000064235.V305667.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 Court DS0000064235.V305667.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 Court DS0000064235.V305667.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): 1, 2, 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including information taken from a previous visit to this service. Service users are made aware of what they can expect to receive for their money when they stay at Lee Court. Service users needs and wishes are recorded during the assessment process however guests may be vulnerable if this information is not transferred into the care plans. EVIDENCE: The homes statement of purpose accurately reflects the service offered at Lee Court. The document was updated following requirements made at the time of the last inspection of the home. The latest report of a ‘Regulation 26’ visit by a representative from Leonard Cheshire reflected positively on an observation of the manager completing a pre admissions assessment. The manager informed the inspector that she requests community care or overview assessments to support any new referral. Lee Court DS0000064235.V305667.R01.S.doc Version 5.2 Page 10 Information in relation to likes, dislikes and preferences for personal support is recorded on personal support plans. The manager stated that plans are developed from assessments and liaisons with prospective service users, family members and other appropriate agencies. The inspector reviewed two plans in detail and found that some information seen on an overview assessment was not reflected in the personal support plan. In discussions following the inspection the area manager stated that this is because often behaviours noted in these plans are not witnessed when guests stay at Lee Court. It was agreed that when this happens the organisation would ensure that differences are justified within the care plan. The manager reported that contracts had been developed between the organisation and the service user and had all been sent out for signing. On the day of the second inspection visit it was reported that one contract had been returned. The inspector acknowledges that given the nature of the service provided this process might take some time to complete. This standard will therefore be reviewed at the time of the next inspection visit to the home. Lee Court DS0000064235.V305667.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, 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including information taken from a previous visit to this service. Service users are supported to enjoy their stay at the home by a staff team who have knowledge of their individual support needs however guests may be vulnerable if written records do not reflect this knowledge. Service users value being able to make choices during their stay at Lee Court. EVIDENCE: The manager reported that she has recently completed a Personal Support Plan for all guests who use the service. The support plans of the two guests, staying at Lee Court at the time of the inspection, were reviewed by the inspector. Both plans were written in a very person centred way and individual needs and preferences were recorded. However the plan for one service user referred to a behavioural support plan which was not available. The manager was left an immediate requirement to produce this plan given that it related to Lee Court DS0000064235.V305667.R01.S.doc Version 5.2 Page 12 managing identified complex behaviours. At the time of the second visit to the home this plan was in place although it did not reflect all information in the guests overview assessment. (See explanation detailed in evidence for previous standards) The manager detailed behaviours of a guest not currently staying at the home and explained that as a safeguard the TV is removed from her room when she visits. Upon review of her file there was no evidence of the behaviour or the action taken. Likewise risk assessments continue to require a lot of work to make them person centred and available when PCPs say they are. It was of concern that although appropriate documentation was available to record risk assessments there was confusion as to which format to use. The manager stated that risk assessments for activities would be carried out on the service user specific assessments however timescales for the completion of such assessments have been made by CSCI at previous inspections. Workplace risk assessments were being used for service users and a number remain outstanding. Issues in relation to risk assessments on this occasion will be reviewed as part of the ‘conduct and management of the home’ standards and will support the overall quality rating for that standard. It was noted during a meeting with senior managers for the organisation held at CSCI office on 6th September 2006 that all risk assessment have been reviewed and revised by the area manager and the home manager since the inspection. Moving and handling risk assessments had been completed for both guests currently staying at the home. They are currently due for review. Improvements were also noted to the individual files. For example each service user has a ‘grab sheet’ containing all necessary information should a guest require hospital or emergency treatment. Service users who spoke with the inspector stated that they were able to make choices during their stay. One service users said that if she didn’t like the meal on the menu she could request an alternative and one service users stated that she was able to choose her room, preferring the ‘quiet one’. The home demonstrated it could be flexible in relation to outings and meals. One evening service users requested a pizza night and on another occasion everyone enjoyed an impromptu BBQ. Lee Court DS0000064235.V305667.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, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including information taken from a previous visit to this service. Service users are supported to attend their usual social commitments throughout their stay at Lee Court and have opportunities to participate in new activities within the local community. Service users are offered a varied and balanced diet. EVIDENCE: Service users accessing Lee Court continue to attend their pre arranged day services. Likewise staff at Lee Court support guests to access their identified evening leisure and social activities. In addition the home has recently Lee Court DS0000064235.V305667.R01.S.doc Version 5.2 Page 14 implemented an activities programme offering a range of events both in house and in the community. Daily records demonstrate that service users access local events and take advantage of good weather and organise BBQs. The manager reported that there are a couple of local pubs that are particularly popular with guests. Guests attending Lee Court prefer not to engage in developing independent living skills preferring to use the service ‘like a hotel’ (according to the manager). Staff support this ethos and guests who spoke with the inspector stated that this arrangement is something that they ‘look forward to’. Personal support records reflect that routines and preferences are noted and supported. Guests are supported to maintain contact with family and friends as appropriate during their stay. Menus are rotated on a four weekly basis. Due to the nature of the service the menus are made up in advance when staff know which guests will be staying. They then try to cater for individual dietary needs and preferences. Service users who spoke with the inspector stated that they enjoyed the meals and that if they didn’t want something on the menu they could request an alternative. One service user had particular dietary requirements in relation to food additives and the manager stated that he is fully aware of what he can and cannot eat. The manager also gave examples of a guest who, due to cultural differences, couldn’t eat certain foods. Lee Court DS0000064235.V305667.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 adequate. This judgement has been made using available evidence including information taken from a previous visit to this service. Service users are safeguarded by appropriate systems for recording and administering medication. Service users benefit from a knowledgeable staff team who support them in ways that they prefer. EVIDENCE: As previously stated care plans contain details of how guests like their personal support to be delivered although some information is missing (behavioural support plans). (See requirement standard 6). Guests are asked to record whether they prefer male or female support although the inspector did not see how this preference was implemented. Staff who spoke with the inspector had worked at the home for a number of years and were knowledgeable about the care and support needs and wishes of the guests. Details of emergency contacts and GPs were seen recorded on care files and the manager is currently implementing a ‘grab file’ for each service user to use in an emergency situation. It was noted that this would provide a valuable Lee Court DS0000064235.V305667.R01.S.doc Version 5.2 Page 16 resource. The sheet was not one of the organisations own formats. The manager had utilised a proforma from another source. As the inspection took place on a ‘handover’ day there was only one service user in residence at the time the medication arrangements were reviewed. Medication was seen to be stored appropriately. Records were with the individual file however it was seen to have been completed appropriately. The home has installed a lockable cabinet for storing controlled medication and have implemented a book to support its use. The cabinet was empty upon inspection. Staff have undertaken training specifically in relation to the administration of one named medication for an identified service user. Certificates and staff discussions demonstrated this. Lee Court DS0000064235.V305667.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 adequate. This judgement has been made using available evidence including information taken from a previous visit to this service. The home’s pre existing complaints recording procedure is inappropriate as information of a confidential nature is held centrally and outcomes are not logged. The new procedures when implemented will provide better protection for guests and their representatives. Service users are protected by the homes access to training in adult protection matters however financial procedures are not robust enough to demonstrate accountability. EVIDENCE: The manager stated that the home has recently implemented a new complaints procedure. Report forms are downloaded off the intranet and therefore were not seen at the time of the inspection. It was not clear how these forms would be used or stored although the manager and the staff stated that they had received training in its implementation. The manager stated that all complaints are dealt with within 28 days. The last complaint about the service was on 05.05.06. The recording of this complaint was inappropriate and there was no evidence of a suitable outcome being reached although the manager recalled the process to her satisfaction. The manager stated that all staff had undertaken adult protection training and staff on duty at the time confirmed this. Staff have also accessed complaints and whistle blowing training in-house. The manager has, in addition, completed the POCA training as good practice. Lee Court DS0000064235.V305667.R01.S.doc Version 5.2 Page 18 The financial records were reviewed for one service user. The process requires that records are kept for all transactions of service users money and receipts are retained where available. The record seen did not show a clear audit trail as to where the money was at any time as it is not recorded if the service user retains his change or if no receipt is available. The manger stated that records are given to carers at the end of the stay leaving the home with only a photocopy of the sheet (not the receipts). It was recommended that the manager review this arrangement to ensure it allows the organisation an audit trail of financial accountability. Lee Court DS0000064235.V305667.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, 30 Quality in this outcome area is good. This judgement has been made using available evidence including information taken from a previous visit to this service. Lee Court is well maintained and decorated with a high standard of cleanliness throughout providing a very pleasant environment for its guests. EVIDENCE: As part of the inspection the inspector was given a tour of the premises by the manager and the deputy manager. All areas were found to be clean and tidy with improvements noted since the time the inspector last visited the service. New carpets had been fitted in the lounge and new bedroom furniture purchased. All rooms looked bright and welcoming. Some pictures displayed in the hallway had been done by guests and one guest had made throws for chairs. At the time of the inspection a power cut enabled the deputy manager to demonstrate her safety checks in relation to fire safety and emergency lighting. The only issue arose when a self-closing fire door would not close due to the pile on the new carpet. The deputy manger stated that it had been Lee Court DS0000064235.V305667.R01.S.doc Version 5.2 Page 20 working earlier that day but the door had been ‘pushed too far back’. She committed to ensure that this does not happen again. Bath temperatures are recorded on all occasions and records were seen to reflect this. Temperatures for the bath water ranged from 34 degrees to 36 degrees. Both the manager and the deputy stated that these temperatures were not too cold to bathe in. It was positive to note that the ‘Heat wave Programme’ had been implemented within the home. Personal protective equipment was seen throughout the home and staff stated that it was readily available for use. The home has developed an emergency service plan that contains vital information and contact details for an emergency situation. Lee Court DS0000064235.V305667.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 adequate. This judgement has been made using available evidence including information taken from a previous visit to this service. Service users benefit from a committed and enthusiastic staff team who are receiving good training opportunities. The quality of care provided to service users may be compromised if staff do not receive regular formal and recorded supervision or a structured induction. Service users are protected by the organisations procedures for obtaining pre appointment safety checks. EVIDENCE: There are always two members of staff on duty for each shift at Lee Court unless a named individual is staying when this number increases. The rota reflected this arrangement. Staff who spoke with the inspector were committed to the home and to the service users. They were knowledgeable about individual needs and stated that since being employed by Leonard Cheshire have had access to numerous training opportunities. Discussions with a family member visiting the home at the time of the inspection demonstrated that the manager and staff team are approachable and effective. Lee Court DS0000064235.V305667.R01.S.doc Version 5.2 Page 22 Senior staff have recently been delegated responsibility for supervising support staff. Files reviewed as part of the inspection reflected recent requirements by the organisation that supervisions should be carried out on a regular basis. Both staff whose files were reviewed required an up to date supervision. One of the two files reviewed contained evidence of a recent appraisal. The manager stated that the staff member who had not received her appraisal was a staff member who didn’t work regular hours. Staff spoke very highly of the support they received from the manager and felt there was a good ‘team spirit’ at the home. Staff files reviewed contained the majority of required information. Information seen at the time of the inspection did not reflect arrangements actually in place in relation to the availability of CRB disclosures. Appropriate procedures had been noted at the time of the last inspection of the home although this was not shared with the inspector on this occasion. The manager was however advised to destroy photocopies of CRB disclosures, which she did immediately. Likewise the manager could not explain why there was no documentation to demonstrate that the latest member of staff to join the team had received a satisfactory induction to the service. The supervision file for the deputy manager demonstrated that she receives regular supervision and had had an appraisal on 29/5/06 where objectives for the forthcoming year were identified. Training opportunities for staff include modules relating to the LDAF including most recently infection control and safe handling of medication. Although staff felt that this was a lot of work they remained optimistic that it would be beneficial to their work practice. Staff undertake training as part of their rotad hours. The manager reported that all staff but one have achieved NVQ level 2 in Care and support is being offered to one staff member to study. Lee Court DS0000064235.V305667.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, 43 Weaknesses continue to be identified in this outcome area however input from senior managers means that issues are being addressed to ensure the ultimate safety of the service. It is therefore believed that overall quality in this outcome area is adequate. This judgement has been made using available evidence including information taken from a previous visit to this service. Current in house management arrangements are inadequate and demand an urgent review to ensure that the health and safety of service users and staff is not compromised. EVIDENCE: A review of COSHH storage and recoding identified that products were being kept securely with access to staff only. Only one of the two products chosen at random were supported by a data sheet and risk assessment. The staff member who supported the inspector with this review was sure that she had seen it in the past. Lee Court DS0000064235.V305667.R01.S.doc Version 5.2 Page 24 The home now uses a new book for reporting and recording incidents within the home. The book complies with data protection legislation and although only used once it was evident that the manager and the deputy were unaware of the recording and storage process. The administrative assistant had removed the counterfoil sheet and faxed it to head office. No reason could be given for this. Risk assessments were seen for moving and handling and workplace issues however some of these were due a review. Different formats were available for carrying out risk assessments and it was evident that there was confusion as to which format is appropriate (see information and requirement standard 9). The manager has completed training in relation to risk assessment. Fire safety recording was accurate and up to date. The deputy manager demonstrated a sound knowledge of checking and recording procedures in relation to fire safety. Communication between the administrator and the manager needs to be addressed, as the manager is ultimately responsible for all decisions made and practices followed. The manager did not have access to all required information and the computer she uses is onerous and doesn’t support her work. The quality of the overall record keeping remains poor. The manager works on shift usually three days a week having to perform administrative and managerial tasks in the remainder of her working week. This arrangement must be reviewed as evidence within this report suggests that the manager does not have the time (or the skills) to carry out essential management tasks and this is seriously impacting on the quality of the records and safety processes within the service. It is noted that the organisation has offered support and training to the manager and in addition the area manager has spent time at the home reviewing processes. The manager has made efforts to try and establish the views of service users by way of questionnaires that have been sent out formally and informally. Response to these questionnaires has been poor. The manager continues to think creatively as to how a better response can be obtained. The manager is well respected by the team and service users and is knowledge of each person’s individual needs. The manager of the service was refused registration with CSCI due to issues relating to her ‘inexperience’. She now has the Registered Managers Award and has completed training in supervision procedures, managing sickness and absence and the LDAF induction programme. She is awaiting information to commence the NVQ level 4 in Care. It appears from the manager’s response to matters raised during this inspection, and referred to elsewhere in this report, that there are areas of weakness in terms of being able to apply and develop best practice within the home. However, levels of support from the Lee Court DS0000064235.V305667.R01.S.doc Version 5.2 Page 25 organisations area manager have lead to improvements since the last inspection. Lee Court DS0000064235.V305667.R01.S.doc Version 5.2 Page 26 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 2 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 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 2 2 3 X 1 X 3 X 2 1 2 Lee Court DS0000064235.V305667.R01.S.doc Version 5.2 Page 27 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 (1) (2) Requirement Individual support plans must contain information to ensure staff are fully aware of how care is to be delivered for each individual. (Previous timescale of 12.09.05 and 31/03/06 not met). Assessments must be used to accurately inform care and support plans. Risk must be assessed prior to admission and service users enabled to take responsible risks within a risk-assessed framework, which is regularly reviewed and updated for, all in house and community activities. (Previous timescale of 15.08.05 and 31/03/06 not met). Timescale for action 21/08/06 2 3 YA2 YA9 14 (1) (a) (b) 13 (4) (b 21/08/06 21/08/06 4 YA22 22 (3) (8) 5 6 YA36 YA37 18 (2) 9 (2) (b) (1) Complaints recording, monitoring 11/09/06 and logging of outcomes must reflect confidentiality of information and data protection guidelines. Staff must receive regular formal 28/08/06 and recorded supervision The manager must be aware of 14/08/06 her roles and responsibilities in DS0000064235.V305667.R01.S.doc Version 5.2 Page 28 Lee Court 7 YA42 13 (4) (a) 8 YA37 YA43 9 (2) (1) 9 YA41 17 (1) (2) (3) (b) relation to the running of the home. Products used for cleaning must 14/08/06 be accompanied by data sheets and risk assessments to promote their safe usage. The organisation must conduct 14/08/06 an urgent management review of the home to ensure that the manager has the skills and the time to fulfil her role. The manager must implement 28/08/06 systems to complete and store records to ensure confidentiality and maintain monitoring procedures for accidents and incidents. 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 YA23 Good Practice Recommendations It is recommended that a review of the financial audit trail for service users money takes place to ensure protection and accountability Lee Court DS0000064235.V305667.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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. 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