Inspection on 11/08/06 for Leigh Bank

This inspection was carried out on 11th August 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Leigh Bank 25/01/06

Leigh Bank 26/10/05

Leigh Bank 05/01/05

Leigh Bank 07/07/04

Similar services:

Littledale Hall Therapeutic Community

Bennett House

Padgate House

Mary & Joseph

Westcliffe House

Richards House

Hamer Cottage

Turning Point (Hoole Road)

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

CARE HOME ADULTS 18-65 Leigh Bank Leigh Bank 4 Glebelands Road Prestwich Manchester M25 1NE Lead Inspector Lucy Burgess Unannounced Inspection 11th August 2006 09:45a Leigh Bank DS0000008455.V297662.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 Leigh Bank DS0000008455.V297662.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. Leigh Bank DS0000008455.V297662.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Leigh Bank Address Leigh Bank 4 Glebelands Road Prestwich Manchester M25 1NE 0161 773 1523 0161 773 0125 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) Turning Point Care Home 11 Category(ies) of Past or present alcohol dependence (11), Past or registration, with number present drug dependence (11) of places Leigh Bank DS0000008455.V297662.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Within the maximum registered numbers there can be up to 11 people with past or present alcohol dependence and up to 11 people with past or present drug dependence. The service should employ a suitably qualified and experienced Manager who is registered by the Commission for Social Care Inspection. 25th January 2006 2. Date of last inspection Brief Description of the Service: Leigh Bank is an 11-bedded residential care home for younger adults (18yrs 65yrs) with problems associated to drug and alcohol misuse. At the time of the inspection only 8 people were resident at Leigh Bank. Fees are charged at £359.00 per week. The property is situated in Prestwich, Manchester and is close to the M60 motorway network. It is convenient to local shops, leisure facilities and the metro tram network. The accommodation is an old Victorian style semi detached house in keeping with other properties within the area. The accommodation comprises of 7 single bedrooms and two double rooms. All services such as heating, lighting, food, accommodation, staffing costs and laundry facilities are included as part of the fees. A large well maintained garden is available to the rear of the property. Leigh Bank DS0000008455.V297662.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over one day. The inspector spent time looking round the home, viewing records as well as talking with residents and staff. Discussion and feedback was also held with the Manager. The home is registered to provide accommodation for 11 people. At the time of the visit the home had 3 vacancies. Although the inspection was unannounced the completion of a pre-inspection questionnaire was requested. Feedback surveys were distributed however no questionnaires were returned. All the key standards were looked at during this inspection visits. What the service does well: What has improved since the last inspection? A new risk assessment form has been introduced. This provides clear information about the area of concern, how support is to be provided and by who, making sure that service users are safe. The Team Leader is now ready to submit his application for Registered Manager to the CSCI. Some redecoration has been carried out as well as new items purchased for the use of residents. This has made some improvement to the environment and provides a comfortable environment for the residents. Leigh Bank DS0000008455.V297662.R01.S.doc Version 5.2 Page 6 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. Leigh Bank DS0000008455.V297662.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Leigh Bank DS0000008455.V297662.R01.S.doc Version 5.2 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 the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The system of assessing prospective residents prior to admission to the home gives an assurance that a resident is only admitted if the home is able to meet their needs. EVIDENCE: Assessment documents have recently been reviewed and updated. The home has 2 documents, which are utilised, one could be forwarded to service users to complete and a member of the team would complete the second. Assessment are generally undertaken at the home however where necessary staff will go out to meet prospective residents or carry out assessments over the telephone. Referrals are accepted from both health and social care professionals as well as self referral. Where professional agencies are involved previous assessments and relevant information are also requested providing the home with comprehensive information about the needs of service users prior to agreeing placement. On examination of the documents, these were found to be comprehensive and included the social, emotional and psychological needs of individuals. Information also explored past history of drug/alcohol use, previous detoxification and rehab, prescribed medication and any convictions etc. Leigh Bank DS0000008455.V297662.R01.S.doc Version 5.2 Page 9 Completed documents were seen for two of the residents. Information provided staff with details of their addictions as well as identifying areas of risk. This information is then used to develop the care plan. Leigh Bank DS0000008455.V297662.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments were detailed and reflected the care needs of residents providing staff with clear information about how their needs should be met. Residents expressed that they were well supported and fully involved in making decisions about their lives. EVIDENCE: Each of the residents have a care file, which includes all relevant information regarding their placement at the home. Information held includes the initial assessment and care plan, current plan, risk assessment, correspondences as well as policies, procedures or other information about the resident. Files were examined for 2 residents, one of which had only been at the home for 3 weeks. Information held included the initial care plan, which was completed on admission. This is expanded upon the following month to include more details about the individuals goals, risks etc. Leigh Bank DS0000008455.V297662.R01.S.doc Version 5.2 Page 11 Information in relation to risk areas had also been completed. New documentation had been implemented and provided clear information to all parties in relation to what the identified risk is and how this is to be managed. Information continues to be provided to the funding authority with regards to the residents’ progress along with an up to date copy of the care plan. Due to placements being on a relatively short term basis, for example 3, 6 or 9 months, the plans are reviewed on a monthly basis to ensure that information is up to date and accurate. Documents had been signed by the residents to evidence their agreement. Specific information is generally discussed within the 1-2-1 sessions. Further documentation is held in relation to consent to information being shared, behavioural policy/agreement, self-medication, and confidentiality and licence agreement however not all have been signed and dated. Information is held securely within the staff office and easily accessible to staff. Additional records are completed in relation to daily reports. These outline what residents have done throughout the day as well as noted from the 1-2-1 sessions therefore providing information, which could be used for monitoring purposes. As the project provides rehabilitation support individual needs change as the programme of recovery is worked through. The home is strict in relation to breaching the homes ‘rules’. Any breaches would result in notices being issued with a time frame for improvement or termination. This ensures that other residents are protected. All incidents are documented and placed on file. Issues would then be discussed within the 1-2-1 sessions. Residents spoken with confirmed that they were aware of the ‘rules’ and consequences if broken, however felt that this was fair due to reasons they were staying at the home. As the project is relatively small, informal day-to-day contact is made between residents and staff, which continues to enable the views and opinions of both parties can be easily aired. This method is used as well as formal meetings and discussions. The inspector spoke with 4 residents, feedback was extremely positive about the support they receive and how the programme was enabling them to move forward. Comments included Comments included ‘everyone is so supportive’, ‘they’re easy to talk too’, ‘I feel safe’ and ‘we all help each other’. One resident also stated that the group work had helped him to develop his confidence as well as talk about concerns rather than keeping them all in. Another resident had only been at the home for 5 days however felt that everyone had made her feel very welcome and safe, which had reduced her anxieties about going into rehab. Leigh Bank DS0000008455.V297662.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Encouragement and support is provided enabling residents to build on their confidence and develop new skills as well as increasing their ability to be independent for when they move away from rehab. EVIDENCE: Routines within the home include attending set group work sessions as well as exploring other opportunities based on their own particular interests. Residents are expected to attend all group work sessions as part of the programme with the focus on them to explore other opportunities and learn/regain skills as part of their rehabilitation. A number of residents were exploring courses available at local colleges, these includes areas of health and social care as well as engineering. In relation to leisure time, this is at the discretion of each person. Some of the activities undertaken have included, art work sessions, bike rides, bar-b-ques, Leigh Bank DS0000008455.V297662.R01.S.doc Version 5.2 Page 13 visiting the local park and boating lake, shopping, attending the Buddhist centre, yoga classes as well attending the local church. The home is also exploring the possibility for the Internet to be installed for the residents’ use, which will enable residents to develop other interests and skills. Discussion is also held within the residents Friday morning group where residents discuss weekly event, weekend plans, and life in the house as well as delegating domestic and shopping tasks between them. This enables the residents to be actively involved in the running of the home as well as taking on responsibility for some of the weekly tasks that need to be completed. Contact with family and friends are maintained. This is based on the wishes of each individual with contact allowed following the initial settling in period. In relation to meals, residents take it in turn to do the shopping for the house. Residents make their own arrangements with regards to breakfast and lunch. Residents then take it in turn to cook the evening meal for the group. Recently one of the project workers who is a qualified chef has been supporting residents in preparing different meals, these have included, southern fried chicken, spiced meatballs and prawns in cream sauce. Residents spoken with expressed that they were enjoying this and that the project worker was ‘helping us learn new things’ another comment included ‘I’ve never eaten so well since coming here!’ The home had recently accommodated two residents, a Muslim couple, who kept a halal diet. Arrangements were made for separate storage and refrigeration as well as crockery and cutlery so that they were able to maintain their religious and cultural beliefs. Leigh Bank DS0000008455.V297662.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The programme of support provided within the home along with the support of relevant health and social care professionals who assist residents in addressing their addiction as well as maintaining their independence whilst in rehab. EVIDENCE: Residents living at Leigh Bank are not always from the local or surrounding area, therefore need to be registered with the local GP. Access to other health care professionals is also made available should this be required. This may include the optician, chiropody or dentist etc. As previously identified where individuals have additional needs such as mental health needs, psychiatric services would be accessed to offer further support and advice. This information would be detailed on the initial assessments and the care plan. The programme within the home also provides support in relation to individual emotional needs and managing addiction. This is done within the group work sessions as well as 1-2-1 discussions with staff members. This enables residents to explore issues or concerns within a safe and supported environment. Leigh Bank DS0000008455.V297662.R01.S.doc Version 5.2 Page 15 Generally each of the residents living at the home are able to manage their own personal care needs however where prompts and encouragement are needed to enable residents to increase their independence this too is provided. Bathing facilities are available on each floor, therefore easily accessible. In relation to the management of medication this is generally the responsibility of the residents. Individual risk assessments have been completed, which explore the residents’ awareness of managing their medication as well as safe storage. Should serious concern be identified then the staff would hold medication if the office and individuals would be support in administering safely and as prescribed. As residents are registered with different GP surgeries medication is dispensed in the usual containers i.e. bottles or blister packs. Since the last inspection a system of monitoring medication has been implemented. An up to date record is maintained with regards to prescribed medication with regular checks on stocks and storage. Each member of the permanent staff team have also completed Boots medication training at both foundation and advanced level therefore having a better knowledge and understanding of the medication prescribed for residents. As already stated the residents are expected to follow the rules of the home with regards to abstaining from any alcohol or drug use. This is monitored through periodic testing to ensure that the well being of all residents is not compromised whilst working through the rehab programme. Leigh Bank DS0000008455.V297662.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Satisfactory arrangements are in place in relation to the protection of service users as well as responding to their concerns. EVIDENCE: Policies and procedures in relation to the protection of vulnerable adults are held by the home. All members of the team have now completed training in this area. Residents are also given copies of the complaints procedure. This is also included within the residents’ handbook, which is currently being up dated. Copies of these documents are provided to all new residents. Information provided within the pre-inspection questionnaire identified that 3 complaints had been received by the home. Through discussion with the Team Leader, appropriate action had been taken to address and resolve the issues raised. Each of the residents spoken with expressed that they were confident in raising any concerns with staff and that issues would be dealt with. In relation to residents’ finances, the staff will collect rent money each week with remaining monies being held and managed by individual residents. Each has their own bank accounts. Money is only held where a risk as been identified and would be part of the agreement. Turning point provided comprehensive policies and procedures with regards to ensuring the safety and protection of individuals residing at each of the projects. Copies of the documents were available at the home. Leigh Bank DS0000008455.V297662.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Leigh Bank provides a homely environment for those that live there. On-going redecoration and refurbishment is needed due to placements being short term, this will ensure that a reasonable standard is maintain within the home. EVIDENCE: Leigh Bank is a small home set within a residential area of Prestwich and provides support for up to 11 younger adults with problems associated to drug and alcohol misuse. The house is spacious and indistinguishable from those around it. Accommodation consists of 2 lounges, one of which is the designated smoking area, a dining kitchen, 2 bathrooms, 3 showers and 5 toilets. There are also 7 bedrooms and 3 double rooms. Only one of the rooms, the lodge, has en-suite facilities. There is also a staff office on the first floor. Those wishing to are able to personalise their room to their liking. The home also has well maintained gardens to the front and rear of the property. Leigh Bank DS0000008455.V297662.R01.S.doc Version 5.2 Page 18 Work has been undertaken both in and outside of the home. The exterior has had work carried out to prevent the on-going damage caused by pigeons. Security lighting has been installed to the rear and side of the property as well as iron fencing to the side. This provides more security to the home. Earlier in the year some redecoration took place, which included the kitchen and some of the bedrooms. New dining furniture has been purchased along with a television and DVD for one of the lounges. Due to placements at the home being short term, on going redecoration is necessary in order to maintain the home to a reasonable standard. Two residents spoken with expressed they were comfortable within the home and were able to enjoy the privacy of their own rooms as well as spending time with other in the communal areas. Each of the residents continue to be encouraged in taking responsibility for domestic tasks. A residents’ meeting is held each week, this is chaired by the resident’s rep and agreements are made in relation to delegating the work to be completed. Leigh Bank DS0000008455.V297662.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All relevant information in relation to the recruitment and selection of staff needs to gathered ensuring the safety of residents. Training has been identified to equip the staff with the knowledge and skills needed in meeting the needs of residents. EVIDENCE: Staffing currently comprises of the Team Leader, 2 project workers and resettlement worker. At present the team at Leigh Bank is going through some change. A full-time project worker and the administrator have recently left the home and the resettlement worker is going on secondment. Recruitment has been taking place and a new administrator appointed. Further recruitment was planned following the inspection to recruit a new project worker. At present agency staff from ‘Top Care’ are being utilised to cover the shifts, regular workers are being used to offer continuity. Through discussion with the Team Leader consideration is being given to reviewing the current rota system. This would involve all staff working over a 7-day rota covering each day and evenings. Staff are not on site during the night. Should there be any issues residents are able to access support via the on-call facility. Leigh Bank DS0000008455.V297662.R01.S.doc Version 5.2 Page 20 The personnel file for the newest member of the team was examined along with information on 2 of the agency staff regularly used by the home. In relation to the permanent worker no information was found other than personal details. The Team Leader advised that the worker is based at another home as well as Leigh Bank and therefore information was possibly held elsewhere. It was advised that evidence of the relevant checks as required under schedule 2 are placed on file. In relation to the agency staff, confirmation had been forwarded by the agency stating that references had been sought and an enhanced criminal check completed. Evidence of these and any relevant training was available on request. In relation to staff training course have been completed in medication, foundation and advanced, protection of vulnerable adults, group work and motivational interviewing however these have yet to be completed by all staff. Further training has been identified, this includes person centred planning, group work, motivational interviewing and health and safety as well as a fire marshal training and appointed first aider. The Team Leader is to ensure that all staff including those newly appointed complete all the identified courses. Additional training in NVQ has also been identified for staff. Leigh Bank DS0000008455.V297662.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A clear management structure is in place providing both residents and staff with the support needed. Areas in relation to health and safety need to be address ensuring both residents and staff are protected. EVIDENCE: The Team Leader has now worked at the home approximately 12 months. Information and an application has now been completed with regards to becoming the Registered Manager. This is to be submitted to the CSCI Registration Team. The Team Leader has many years of experience working with individual with substance misuse problems. Currently he is completing a Post Graduate in Emotional Education, Diplomas in Stress Management and Yoga as well as considering a Master Class in Hypnotherapy and Behaviours. Management training in line with Regulation is still required. Leigh Bank DS0000008455.V297662.R01.S.doc Version 5.2 Page 22 His management role involves the day to day management of the home, delegating tasks to members of the team, ensuring areas of health and safety are addressed as well as supporting and encouraging service user involvement. The Service Manager who spends time at the home each week supports the Team Leader in his role. Both managers also meet regularly for supervisions where action is identified along with timescales for completion. The Team leader expressed that he feels fully supported by his Manager. In relation to quality monitoring systems the monthly reports had been completed by the Service Manager however had not been undertaken since the last inspection. These should be completed and held on file so that they are available for inspection if requested. The manager had also received satisfaction surveys to be completed by the residents from the National Treatment Association (NTA), exploring the experiences of those who have received a service. The Turning Point Co-ordinator for Service User Involvement has also visited residents so that he could actively seek out the views of residents as part of the organisations monitoring systems. In relation to the day to day running of the home decisions are clearly made with the involvement of the residents. Residents continue to have weekly meeting where they are able to discuss their views and opinions about the home as well as plan the forthcoming week. Information was examined with regards to safety checks carried out within the home. Certificates were seen for gas, fire alarm, fire equipment, emergency lighting and small appliances. As previously identified evidence should be provided of the 5-year electrical check. Information provided within the PIQ stated that this had been completed in March 2006 however a certificate was not seen during the visit. In house checks are also carried out using the ‘health and safety monitoring checklists’. Further checks are also undertaken with regards to sounding the fire alarm and checking equipment and emergency lighting. Previously fire training is undertaken with residents on admission, this includes watching a video and completing a questionnaire. Of the residents files examined information was found on file however had not been completed. The Team Leader should ensure that all residents are clear about the procedure to follow. Action should also be taken with regards to the general risk assessments. Whilst some of these had been reviewed and updated others had not, dating back to 2003. Leigh Bank DS0000008455.V297662.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 2 X Leigh Bank DS0000008455.V297662.R01.S.doc Version 5.2 Page 24 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 YA34 Regulation 19 Requirement That evidence is place on file for the newest staff member with regards to the checks carried out as outlined within schedule 2. (previous requirement) That the general risk assessments are reviewed and updated where necessary. That evidence of the NEICE electrical test certificate is forwarded to CSCI as previously requested. (previous requirement) Timescale for action 30/09/06 2. YA42 13 30/10/06 3. YA42 23 30/10/06 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 YA35 Good Practice Recommendations That the Team Leader ensures that all staff complete the programme of training identified. DS0000008455.V297662.R01.S.doc Version 5.2 Page 25 Leigh Bank 2. 3. 4. YA37 YA42 YA42 That arrangements are made for the team leader to commence the relevant management training. That video training in relation to fire safety is completed with the residents. That an up to date fire drill is carried out with staff and residents. Leigh Bank DS0000008455.V297662.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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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