Inspection on 28/06/05 for Lee Court - Leonard Cheshire Disability

This inspection was carried out on 28th June 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

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

Lee Court - Leonard Cheshire... 21/07/06

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

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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 TF1 1EH Lead Inspector Rebecca Harrison Announced 28 June 2005 13:00 th 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 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 Stationary 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 E56 S64235 Lee Court V231595 AI 280605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Leonard Cheshire Lee Court Address 2, Lee Court, Queen Street, Wellington, Telford, Shropshire, TF1 1EH Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01952 272020 01952 272050 Leonard Cheshire The manager, Ms Dorothy Neill is not yet registered with CSCI. Care Home 5 Category(ies) of Learning Disability (3) registration, with number Learning Disability over 65 years of places (2) Lee Court E56 S64235 Lee Court V231595 AI 280605 Stage 4.doc Version 1.30 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. Date of last inspection 14th March 2005 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. The property is purpose built and comprises a lounge, kitchen/diner, 5 bedrooms a bathroom and level access shower room. The new service provider is Leonard Cheshire Foundation, who were registered with the CSCI in April 2005. The Responsible Individual is Mr Michael OLeary. The Manager of the home is Ms Dorothy Neill, who is not yet registered with the CSCI. 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. Lee Court E56 S64235 Lee Court V231595 AI 280605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Lee Court is a short stay home for people with learning disabilities. The home is registered with the Commission of Social Care Inspection (CSCI) to provide accommodation and personal care for up to 5 persons with a learning disability who can be either up to the age of 65 or over 65 years of age. At the time of this inspection there were three people in residence. The inspection was announced and commenced at 1 p.m. and lasted just over five hours. The manager, deputy, administrator and support workers on duty were most welcoming and co-operated fully throughout the inspection. The inspection was carried out by talking to three service users staying at the home, discussions with managers and staff on duty, observing activity in the home, inspection of records, case tracking and a tour of the environment. The purpose of this announced inspection was to review the progress made by the home since the last unannounced inspection undertaken on the 15th March 2005 by Ms Rebecca Harrison and Mr Michael Moloney, Regulation Inspectors. Twenty-six requirements and five recommendations were made as a result of the inspection. A number of the requirements assessed during this announced inspection of the service have not been met and therefore carried forward for the next inspection. However, it is acknowledged that the team and senior managers have worked very hard to meet the requirements made by the CSCI and that the change of provider caused least disruption to the people using the service. No complaints have been referred to the service or the Commission for Social Care Inspection since the service was last inspected and there have been no referrals made to adult protection. What the service does well: The transition of service from Telford and District Mencap to Leonard Cheshire was smooth causing least disruption to the people using the service. The new provider is committed to training and development of the staff team. Ms Pat Hughes, the General Manager of Leonard Cheshire who is accountable to Mr Michael O’Leary, the Regional Director, closely supports the team. Staff and managers reported that their new managers have been very supportive and approachable. The manager has been allocated a mentor by the new provider who is available to offer her support as and when required. Lee Court E56 S64235 Lee Court V231595 AI 280605 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lee Court E56 S64235 Lee Court V231595 AI 280605 Stage 4.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection Lee Court E56 S64235 Lee Court V231595 AI 280605 Stage 4.doc Version 1.30 Page 8 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 standard(s) 1,2 and 5 Appropriate procedures are in place to enable successful short-term admission to the home, however the service user guide and a contract/statement of terms and conditions remain outstanding. EVIDENCE: The registered new provider, Leonard Cheshire has produced a Statement of Purpose for the Lee Court and this was forwarded to the CSCI in preparation for the inspection. The document contains all the relevant information required by Schedule 1, Regulations 4 and 5 of the Care Homes regulations 2001. It was reported that the Service User Guide is still being developed and not available for inspection. This document will be reviewed at the next inspection of this service. The home currently provides a short stay service to forty service users who are accommodated for one or two weeks at any one time. Referrals are made through the Joint Community Learning Disability Team based at Tan Bank, Wellington and the appropriate assessments undertaken. The Administrator reported that available dates for admission are sent direct to parents of the service users and that availability is restricted to six weeks per year in the first instance, to allow all service users the opportunity to book the same number of weeks. People usually book a year in advance and the compatibility of people is considered wherever possible. It was reported that there has to be a minimum of 28 days between visits to the home. Lee Court E56 S64235 Lee Court V231595 AI 280605 Stage 4.doc Version 1.30 Page 9 The manager reported that contracts between the home and service users were in the process of being developed in conjunction with the Contracts Department of the Borough of Telford and Wrekin. Therefore these will be reviewed at the next inspection of the service. Lee Court E56 S64235 Lee Court V231595 AI 280605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7 and 9 Care planning systems currently in place do not adequately provide the staff with the information they need to satisfactory meet service users needs in a consistent manner. EVIDENCE: Four requirements were made at the previous inspection of this service in relation to care planning. Three of these were carried forward from an inspection undertaken by the CSCI on 20th July 2004 and 14th March 2005. These were for care plans to contain information to ensure staff are fully aware of how care is to be delivered for each individual. The changing needs of service users must be recorded to ensure appropriate monitoring and staff awareness. Support plans must be available to ensure staff know how to manage identified behaviours appropriately and consistently and for care plans to be reviewed with the service user at least every six months and updated to reflect their changing needs. The manager reported that new individual support plans (ISP’s) had been sent out for families to complete some time ago and to date only 10-15 plans had been returned to the service. The inspector reviewed the care documentation of the three people currently residing at Lee Court. Information seen on two files was insufficient for staff to have a clear understanding of the needs of the Lee Court E56 S64235 Lee Court V231595 AI 280605 Stage 4.doc Version 1.30 Page 11 individuals, levels of care and the support required in order to provide consistency and continuity of care for the people using the service. It was reported that staff are familiar with the needs of the people accommodated. The recommendation for a key worker system to be introduced is now in place, with each staff member having a designated four people to key work. It was reported that the care documentation will be reviewed and updated every six months or earlier to meet any changing needs. However, this is not reflected in the Statement of Purpose which states every 12 months. The manager reported that the local learning disability team recently held formal reviews for two service users. The manager stated that she was told that she did not need to attend the reviews however has requested a copy of the minutes. The requirement made for all incoming and outgoing transactions for service users finances to be accurate with monies held on behalf of service users has been met. Records were checked against monies held for two people and found correct. A cash tin is now provided in each of the service user bedrooms. It was reported these cash tins are to be replaced with wooden lockable boxes, which are currently on order. One of the people using this service on the day of the inspection, takes responsibility for his own money and discussions held with him evidenced that he is very happy with this arrangement. Parents of service users advocate on behalf of the people accessing short term care at Lee Court. It was reported that the manager and senior support workers are currently undertaking training in risk assessment and have completed an induction for risk management and written assignments are to be submitted at the end of July 2005. The deputy is to attend training on 22nd July 2005. Individual risk assessments require further development. The Health and Safety Officer for Leonard Cheshire have completed risk assessments for the environment. Lee Court E56 S64235 Lee Court V231595 AI 280605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) x EVIDENCE: The intended outcomes for Standards 11 – 12 were not reviewed on this occasion. Standards 13,16 and 17 were inspected at the previous inspection of this service with no requirements being made. Lee Court E56 S64235 Lee Court V231595 AI 280605 Stage 4.doc Version 1.30 Page 13 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 standard(s) 20 Medication procedures have improved with clear and comprehensive arrangements being in place to ensure service users medication needs are met. EVIDENCE: The new provider has implemented a new policy and procedure relating to medicines in the custody of the home dated 16.04.05. These were seen at the time of the inspection and were comprehensive. The manager stated that all staff have been provided with a copy of this. The manager reported that seven staff have undertaken accredited training and gained the certificate in the safe handling of medicines through a distance leaning course provided through Walford College. Four further staff are to attend the training in the near future. The requirement made for the home to have a controlled drug cabinet and book has been met and this was seen in place. The manager reported that only one service user is prescribed controlled drugs. Records held for the administration of medicines appeared satisfactory at the time of this inspection. The manager reported that she is waiting a date for a pharmacist inspection. Lee Court E56 S64235 Lee Court V231595 AI 280605 Stage 4.doc Version 1.30 Page 14 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 standard(s) 22 and 23 The home has a satisfactory complaints procedure in place, which has also been developed in a format appropriate to the needs of the people accessing the service. Staff have a knowledge and understanding of adult protection issues, which protects service users from abuse. EVIDENCE: The home has a new complaints policy and procedure in place provided by Leonard Cheshire. This is also available in a format appropriate to the people who use this service. The procedure is displayed in the reception area of the home. Comment cards received by the CSCI in preparation for the inspection indicate that not all service users or parents are familiar with the homes complaint procedure. Discussions held with one service user during the inspection evidenced that he had an understanding of who to speak to if he was unhappy with the service provided by the home. The home has a complaints book available and this was seen during the inspection with no entries recorded. The Commission of Social Care Inspection has received no complaints since the service was last inspected on 14th March 2005. A “Have your say” leaflet is also available to make suggestions or complaints. Contact details of the CSCI are also included in this leaflet. The organisation aim to acknowledge and deal with any complaint within 21 days. The home has a copy of the local multi-agency adult protection policy and procedure and this was seen at the inspection. No referrals have been made to adult protection since the last inspection. All staff have received training in adult protection on the 15.04.05. A whistle blowing policy is place. Lee Court E56 S64235 Lee Court V231595 AI 280605 Stage 4.doc Version 1.30 Page 15 The manager was advised to obtain details of the local guidelines and training in physical intervention (TPI), and this was actioned during the inspection. Financial systems and procedures are now more robust safeguarding the service users. Lee Court E56 S64235 Lee Court V231595 AI 280605 Stage 4.doc Version 1.30 Page 16 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 standard(s) 24,25,27 and 30 The standard of the environment within this home is satisfactory providing service users with a safe and comfortable place to stay. EVIDENCE: A ‘service emergency plan’ is in place and the manager stated that she has the authority to authorise repairs. All outstanding repairs on the property have been carried out. Bedroom doors are lockable and managers reported that keys are available upon request. A recommendation was made at the previous inspection for all beds to be provided with a headboard for the comfort of service users. This has been complied with. All the beds have been replaced with new beds fitted with headboards. Service users accessing Lee Court are provided with a single room. En-suites facilities are not provided. Room sizes are stated in the homes Statement of Purpose. The carpets in bedrooms one and two, have also been replaced. The décor in three bedrooms has also been touched up in areas. All bedrooms are provided with TV and DVD units, which were recently donated by the friends of Lee Court. It was evident through discussions held with one of the service users that he was very happy this new equipment and he had brought a selection of his own DVD’s into the home to watch. Lee Court E56 S64235 Lee Court V231595 AI 280605 Stage 4.doc Version 1.30 Page 17 The home provides two bathrooms, one with a bath and the other with a level access shower facility. Water temperatures are now tested and recorded. Shared space consists of a large kitchen/dinner and a lounge with sky satellite television, video, a music centre and karaoke machine A patio area at the front of the home is provided and since the last inspection a greenhouse has been purchased for the service users to grow tomatoes for the home. Service users are able to see any visitors whether in their own room or utilise the shared space provided. Staff are provided with sleep-in facilities. The home was found clean and tidy throughout. COSHH products are now appropriately stored. It was reported that three staff have recently finished training in infection control and that other staff will also undertake this distance learning course provided through Walford College. Lee Court E56 S64235 Lee Court V231595 AI 280605 Stage 4.doc Version 1.30 Page 18 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,34,35 and 36 The people accessing this service benefit from a committed and well-trained staff team. EVIDENCE: Managers and staff on duty were seen to communicate well with the three people in their care. They appeared interested, motivated and committed to their work. The training opportunities available through the new provider have enabled team members to develop their knowledge and provide them with the necessary skills required to deliver the service. It was reported that seven staff have achieved an NVQ award and a further three staff are very close to completion. The team at Lee Court consists of a manager, deputy, administrator, two senior support workers, three support workers, three night support workers, three relief support workers and two relief night workers. The home currently has one vacancy for an 18-hour support worker post. Agency staff are not used. The homes own bank staff or permanent staff cover sickness, annual leave and training. The duty rota was seen which indicates a minimum of two staff on duty at all times when providing direct care to the people using the service. A sleep-in staff member and a waking night staff member cover the home during the Lee Court E56 S64235 Lee Court V231595 AI 280605 Stage 4.doc Version 1.30 Page 19 night. It was reported that there is usually a senior staff member on duty throughout the day. The home does not provide day care and service users attend their usual day service provision throughout the week. It was reported that the home only provides staffing during the day when day services are closed or if service users fall sick. Comments gained through comment cards forwarded to the CSCI in preparation for the inspection suggested that staff cover should also be provided throughout the day. Currently if a service user is not provided with day services through the local authority a payment is charged for the individual to remain at Lee Court if staff are not on the rota to work. It was reported that no staff under the age of 21 are currently employed by the home. The last staff meeting was undertaken on 25.05.05. Minutes seen were comprehensive. Senior staff meetings are also regularly held. A requirement was made at the last inspection for the manager to undertake training in recruitment and selection prior to recruiting any further staff. The manager stated that both she and the deputy have completed this training through the personnel department on 19.05.05. Since the home was last inspected on 14th March 2005, one person has been appointed onto the bank staff and commenced duties on 16.05.05. Personnel records for the new employee were scrutinised by the inspector and contained all the documentation required by Schedule 2, of the care Homes Regulations 2001, with the exception of a recent photograph of the new employee. The administrator will ensure that this is carried out as soon as possible. The personnel file reviewed for the new bank staff member was well-organised and contained evidence of a comprehensive interview conducted by the manager, deputy and administrator. The relevant CRB check had been undertaken and the disclosure was seen and signed off by the inspector. The new employee is currently undertaking induction and shadowing other staff for ten shifts. Discussions held with her indicated that she is enjoying her new role and feels well supported by the team. She and other staff members were seen to interact positively with the people using the service. A Training Co-ordinator and Regional Training Manager support Lee Court. Discussions held with the managers and staff on duty evidenced that with the support of the new provider, both the manager and staff team have been provided with numerous training opportunities appropriate to their job role. A training matrix has been developed and this evidenced that staff have received training on adult protection, fire marshalling, food hygiene, risk assessment, principle of care, individual support plans (ISP’s) and moving and handling. Since the last inspection both the manager and her deputy have received training in supervision on 5th May 2005. Records seen evidence that three members of staff have received formal supervision with their manager. Lee Court E56 S64235 Lee Court V231595 AI 280605 Stage 4.doc Version 1.30 Page 20 The manager has received one formal supervision session with the General Manager. Ms Pat Hughes, the General Manager of Leonard Cheshire who is accountable to Mr Michael O’Leary, the Regional Director, closely supports the team. Discussions with staff indicated that the team feel well supported by their senior managers. The requirement made for staff to have an appraisal has not yet been met and will therefore be reviewed at the following inspection of this service. Lee Court E56 S64235 Lee Court V231595 AI 280605 Stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,39,41,42 and 43 The managers have undertaken a number of training opportunities specific to their role, enhancing their knowledge and skills from which staff and people using the service benefit. The premises are run and maintained in a manner which ensures the safety of the people in residence. EVIDENCE: The manager of the home is Ms Dorothy Neill who has been employed at Lee Court since 1998, initially as a waking night support worker. Ms Neill was appointed to a senior role in 2001 and has been working as the manager of the home since 04.10.03. A registered manager application has been received by the CSCI, who are currently considering this application. Ms Neill is currently undertaking the Registered Managers Award. The manager and deputy are contracted to work 36 hours per week. The manager stated that she is allocated between 20-25 hours per week to fulfil Lee Court E56 S64235 Lee Court V231595 AI 280605 Stage 4.doc Version 1.30 Page 22 her managerial duties. The manager stated that she feels confident that she is able to fulfil her management responsibilities in the allocated time provided. The rest of her time is used to provide direct care to the people using the service. The deputy has 16 hours of managerial time per week. Since the last inspection of this service the manager and her deputy have undertaken training in supervision, risk assessment, health and safety, recruitment and selection, personal administration and sickness, individual support planning and principals of care in addition to mandatory training. The manager has been allocated a mentor by the new provider. Ms Dorothy Neill spoke positively about this arrangement and has had the opportunity to visit two other homes managed by the new provider. She reported that the mentor is available to offer her support as and when required. It was reported that the General Manager, Ms Pat Hughes has also visited the service on a regular basis and undertaken two visits required under Regulation 26 and reports have been forwarded to the CSCI and a copy retained by the home. In preparation for this inspection five comment cards were received from the service users and five from their relatives. The comment cards received in relation to the service offered were generally positive with service users and relatives stating that they are generally satisfied with the care provided. However comments seen evidenced that not all people are aware of the homes complaint procedures or have access to a copy of the inspection reports on the home which needs addressing. One relative stated “The caring and friendly atmosphere is always excellent at Lee Court but a very big problem is the lack of 24 hour care with no support between 9.00am-4pm for clients not attending day services”. Feedback from staff at the inspection indicated that support for the manager has improved, greater training opportunities and supervision. The area that staff feel the service could improve upon is the communication between managers and staff and more involvement with the families of the service users. With the recent change of provider the managers have not yet had the opportunity to develop a formal quality assurance system, based on seeking the views of service users, relatives and stakeholders to measure success in achieving the aims, objectives and statement of purpose for the home. Managers reported that the new organisation has provided two opportunities for the families of the service users to consult with senior managers of Leonard Cheshire and launch a fundraising support group, however there has been little interest shown. A further meeting has been arranged for 05.07.05. The inspection evidenced that there has been an overall improvement to record keeping systems within the home since the service was last inspected, however as reflected throughout this report a number of records are in need of further development to include ISP’s and individual risk assessments. Lee Court E56 S64235 Lee Court V231595 AI 280605 Stage 4.doc Version 1.30 Page 23 COSHH products are now appropriately stored. The manager reported that two staff complete a monthly health and safety check of the environment. Evidence was seen that the bath and shower water temperatures are now tested and temperatures recorded. A new first aid box has been purchased and all staff receive training in first aid procedures. The radiators have been fitted with covers and staff now work to the health and safety policy and procedures developed and implemented by the new provider. Portable electrical appliances have been tested in April 2005. Training records seen evidence that staff have undertaken mandatory training. No inspections conducted by the fire officer or environmental health officer have been undertaken since the home was last inspected by the CSCI. Fire procedures and the new providers health and safety policy are displayed within the home. A smoke detector has been fitted in the loft. Records seen evidence that fire alarms are tested weekly and emergency lighting monthly. A number of staff have undertaken fire marshal training. A maintenance book is in place and the manager stated that she has the authority to authorise repairs. Medication procedures have improved with all staff working to Leonard Cheshire’s new policy and procedures. Health and safety checklists have been developed and implemented. All other health and safety procedures appeared satisfactory at the time of this inspection. Lines of accountability within the home and external management are clearly understood by the staff. As previously stated the provider has implemented a mentorship for the manager and the manager has undertaken training appropriate to the role as identified at the previous inspection. Appropriate insurance cover is provided. Systems are in place for financial planning and quality monitoring. The business and financial plan was not reviewed at this inspection. Lee Court E56 S64235 Lee Court V231595 AI 280605 Stage 4.doc Version 1.30 Page 24 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 2 x x 2 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x 3 x x 3 Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score x 3 3 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Lee Court Score x x 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 2 x 2 3 3 E56 S64235 Lee Court V231595 AI 280605 Stage 4.doc Version 1.30 Page 25 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 1 Regulation 5,6 Requirement A service user guide must be developed in a format appropriate to the needs of the people accessing the service. The Manager must develop and agree a written contract between the home and each service user. Individual support plans must contain information to ensure staff are fully aware of how care is to be delivered for each individual. The changing needs of service users must be recorded to ensure appropriate monitoring and staff awareness. Individual support plans must be reviewed with the service user at least every six months and updated to reflect their changing needs. This must be amended in the homes Statement of Purpose. Risk must be assessed prior to admission and service users enabled to take responsible risks within a risk assessed framework which is reguarly reviewed and updated for all in house and community activities. Timescale for action 12.09.05 2. 3. 5 6 5(b)(c) 15 (1) (2) 12.09.05 22.08.05 4. 6 15 (12)(b) 15 (12)(b) 22.08.05 5. 6 30.09.05 6. 9 13 (4) (b 15.08.05 Lee Court E56 S64235 Lee Court V231595 AI 280605 Stage 4.doc Version 1.30 Page 26 7. 18 36 8. 24(1)(a)(b) (2)(3) 39 9. 17 41 Staff must have an annual 31.10.05 appraisal with their line manager to review performance against job description and agree career development plan. The home must develop and 31.10.05 implement an effective quality assurance and monitoring system based on seeking the views of service users, relatives and stakeholders to measure success in achieving the aims, objectives and statement of purpose for the home. All records required by regulation 31.08.05 for the protection of service users must available and regularly reviewed and updated. 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 22 Good Practice Recommendations It is recommended that all service users/parents be provided with a copy of the homes complaint procedure. Lee Court E56 S64235 Lee Court V231595 AI 280605 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection 1st Floor, Chapter House South Abbey Lawn 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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