Inspection on 30/01/07 for Leighton House

This inspection was carried out on 30th January 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Leighton House 18/11/08

Leighton House 04/11/05

Leighton House 17/05/05

Leighton House 03/12/04

Leighton House 17/08/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Leighton House Merry Den Care 44 Station Street Cinderford Gloucestershire GL14 2JT Lead Inspector Mr Richard Leech Announced Inspection 25th January 2007 11:15 Leighton House DS0000060129.V322299.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 Leighton House DS0000060129.V322299.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. Leighton House DS0000060129.V322299.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Leighton House Address Merry Den Care 44 Station Street Cinderford Gloucestershire GL14 2JT 01594 827358 F/P 01594 827358 merrydencare@aol.com 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) Mrs Denise Carol Leighton Mrs Denise Carol Leighton Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Leighton House DS0000060129.V322299.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th November 2005 Brief Description of the Service: Leighton House was first registered in 2004. The home provides care for two service users with learning disabilities. The property is a two-storey terraced house located close to the centre of Cinderford. Service users are accommodated in single rooms on the first floor. Each bedroom has a hand basin. There is a shared bathroom and toilet on the first floor and a toilet on the ground floor. There is a lounge and a separate dining room, as well as a small garden at the rear with seating. The home provides transport for the service users and supports them to access activities in the local community. The service provider is in day-to-day charge of the home and acts as manager. It was reported that fees for the service ranged from £509 to £519 per week at the time of the inspection. Prospective service users are offered information about the home including copies of the Statement of Purpose and Service Users Guide. Leighton House DS0000060129.V322299.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection began at about 11.15 on a Tuesday morning, lasting for around seven hours. The service provider/manager was present throughout the inspection. Some feedback was obtained from staff and relatives through discussion and survey forms. The two service users also completed surveys and were spoken with during the inspection. Records checked included care plans, risk assessments, healthcare notes, staffing files and information about training. What the service does well: There is a good approach to admissions which helps to ensure that the service only admits people whose needs it can meet. Care planning in the home is good. There are systems for assessing and managing risks. The service has a positive approach to risk, supporting service users to develop their independence. People living in the home are offered meaningful choices in day-to-day life, helping them to feel in control of their lives. They feel able to speak up if they are unhappy about something and are confident that they will be listened to. A varied and individual activity programme is offered, with service users very much in control of how they spend their time. They are supported to become part of the local community and to maintain contact with family and friends. The home provides a varied and healthy diet which respects people’s preferences. People living in the home are given the help that they need with personal and healthcare. They are enabled to look after their own medication, promoting their independence. Leighton House is homely, clean and comfortable. Service users have their own bedrooms are encouraged to personalise them. Support is provided by skilled carers who have access to the training that they need for the role. The home is well run and there are systems in place for checking and improving the quality of the service. This includes asking the service users for their views. Leighton House DS0000060129.V322299.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Leighton House DS0000060129.V322299.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 Leighton House DS0000060129.V322299.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. 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. A satisfactory framework exists for referral and assessment, helping to ensure that admissions to the service are appropriately handled. EVIDENCE: There had been no new admissions since the last inspection. The manager described the process which would take place if there were a vacancy to be filled. This included conducting assessments, visiting the person in their current setting, speaking with others involved in their care such as family members and care staff, offering visits to the service and obtaining as much background information as possible from different sources. The manager said that the admissions process would be more thorough than in the past due to lessons learnt in the domiciliary care side of the organisation. The admissions procedure was viewed. The Statement of Purpose also provides information about the approach to admissions. The Statement of Purpose and Service Users Guide were reviewed and updated in January 2007. In view of there being no new admissions to check this standard is assessed as being met. As with all services, checking of the assessment and admissions arrangements will form part of future inspections to ensure that actual practice accords with the National Minimum Standards. Leighton House DS0000060129.V322299.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A clear system of care planning is in place helping to promote the quality and consistency of support. People living in the home are offered real choices, helping them to take control over their lives. The service has a positive and empowering approach to risk taking, promoting service users’ quality of life and independence. EVIDENCE: Care plans were seen to cover appropriate areas and to give clear, succinct guidance about the support that service users required. Reviews and evaluations were seen to be taking place at regular intervals. The manager described how one service user preferred not to be involved in the care planning process, whilst the other person liked to be very much included. Leighton House DS0000060129.V322299.R01.S.doc Version 5.2 Page 10 The service has begun to look into more person-centred care planning formats. It was agreed that this should continue and that consideration should be given to the different tools in existence and what they might have to offer the people living in the home. Full reviews of both service users’ care plans and risk assessments were planned for March 2007. It was agreed that this would be a good idea in view of significant progress made by one person in particular. Care plans included reference to offering service users choices. People living in the home were seen to be offered choice, such as about food, drink and activities. The manager and staff described how they promoted service users’ decision-making and control over their own lives. There was also considerable evidence of an empowering approach towards promoting independent living skills. For example, service users had made progress with going out and using public transport independently, shopping on their own and increasing their control over their medication and finances. Staff described how they intervened in some aspects of service users’ lives in terms of best interests, for example around promoting a reasonable night-time routine and a healthy diet. The manager and staff demonstrated an awareness of principles around rights, choice and best interests. Sampled records of service users’ finances appeared to be in order. As noted, one person in particular exercises a considerable degree of control over their money. Some loose change was found in a plastic wallet which was said to belong to one service user. Also one receipt was found which included a meal out for the service user and for the accompanying staff member but the records did not indicate that the person had been refunded for the latter. The manager said that the service user had been refunded but agreed that it was not possible to verify this from records. This indicates that greater vigilance is needed to ensure that procedures are followed and that full and complete records are kept of all transactions involving service users’ money. As noted, one person has made great progress with their independence since the last inspection. This indicates a positive approach to risk taking in the service, with people being supported to take appropriate risks in a measured and staged way in order to enhance their quality of life. Written risk assessments were seen to be in place and to consider appropriate areas. Leighton House DS0000060129.V322299.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to take part in activities which correspond to their needs and interests, helping them to lead full and active lives and to be part of the local community. Appropriate support is provided in order that service users can remain in contact with important people in their lives. Arrangements are in place to ensure that service users’ rights are respected and that they are given support to meet their responsibilities. People living in the home are offered a varied and balanced diet which promotes their health and respects their preferences. EVIDENCE: Leighton House DS0000060129.V322299.R01.S.doc Version 5.2 Page 12 Service users described their activities, confirming that they enjoyed how they spent their time. Discussion with the service users and the manager along with checking care plans and daily records provided evidence of the service users being supported to maintain active lives which corresponded to their interests and needs. These included a variety of activities in the local community and using facilities such as cafes, shops and leisure centres. Programmes were seen to cover the weekend as well as Monday to Friday. One person had chosen to go on holiday in 2007 and plans were being made to provide appropriate support. The other service user preferred to stay in the local area and to have occasional day trips. Discussion with service users and the manager, as well as checking records provided evidence that appropriate support is provided for people living in the home to stay in contact with family and friends. Some feedback was obtained from a family member. Comments included that the home provided ‘excellent care’ and that they were made to feel very welcome when they visited. Service users were seen coming and going in a relaxed way. Front door and bedroom keys are provided if requested. Service users were also observed choosing where in the home they spent time. Whilst structured programmes are in place, observation and discussion provided evidence of these being flexible, corresponding to people’s needs and choices at the time. It was suggested that one care plan should be more explicit about a service user being prompted to go to bed at around 10.30, although there was accompanying information about the rationale for supporting the person to maintain a structured routine. There was evidence on file of service users being offered the opportunity to vote in elections. As noted, service users’ independence is strongly promoted. They are also encouraged to develop skills such as cooking, washing and cleaning. Service users were very complimentary about the food served in the home. The manager described how they aim to balance choice with promoting a healthy diet. Menus provided evidence of variety and balance, as well as of service users’ preferences being respected. People living in the home were observed to be offered choices about food and to be involved in preparation. One person is being supported to do more cooking. Leighton House DS0000060129.V322299.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care support is offered in accordance with service users’ needs and preferences, promoting their self-esteem and dignity. Appropriate support is offered to help service users to stay healthy and well. Arrangements are in place to support service users to control and administer their own medication as far as possible, enhancing their independence. EVIDENCE: The Service Users Guide includes reference to promoting service users’ privacy and dignity. There is a policy about supporting people with personal hygiene issues. At the time, personal care support in the home was limited to occasional prompting and to help such as running the bath. Service users confirmed that they were treated with respect and that they were given space and privacy. Leighton House DS0000060129.V322299.R01.S.doc Version 5.2 Page 14 Healthcare records and other notes provided evidence of service users being supported to access routine healthcare according to their needs. It was noted that some chiropody appointments (as evidenced by receipts and the diary) had not been entered onto the general healthcare records. This should be done in order that they form a complete record. A recommendation was made that the service investigate health action planning (the principles and the templates available, including a local version), aiming to implement this. Discussion with the manager and service users provided evidence that people living in the home are supported to keep and administer their own medication, with support if required. Staff are still receiving training about the safe handling of medication, as evidenced by training records and discussion with the manager and staff. This is good practice. The medication policy (dated July 2006) was viewed. Leighton House DS0000060129.V322299.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place which help service users to feel valued and listened to. Measures have been taken which help to protect service users from the risk of harm and abuse. EVIDENCE: The complaints procedure was viewed. The manager reported that there had been no formal complaints since the last inspection. Service users confirmed that they felt able to voice dissatisfaction. Discussion with the manager and records of residents’ meetings provided evidence of service users expressing their views and requesting changes, for example about the décor of their rooms. The home’s policies about whistle blowing and the protection of vulnerable adults were seen. The latter included definitions of abuse and guidance for staff. There was a checklist which indicated that staff may in some situations ‘investigate’ including to ‘interview the person’. Although there was reference to calling the police later in the document, it was suggested that the policy could be reviewed to describe more clearly when staff may not investigate or interview the person in terms of the risk of corrupting evidence if a criminal offence had been alleged. The policy also mistakenly gave the contact details for CSCI under the heading ‘Adult Abuse Advice Service’. Leighton House DS0000060129.V322299.R01.S.doc Version 5.2 Page 16 Service users described feeling safe in the home. Staff spoken with demonstrated an understanding of adult protection issues and confirmed that they had received training in this area. Some staff had not yet received training about adult protection as a course had been cancelled by the training provider. It was reported that all staff would undertake this training as soon as possible. As noted in Standard 34 an issue arose in recruitment and selection which may have placed service users at unnecessary risk. Leighton House DS0000060129.V322299.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A clean, homely and pleasant environment is provided, promoting service users’ comfort and wellbeing. EVIDENCE: The home was checked throughout apart from one bedroom. Service users expressed satisfaction with their rooms. The bedroom seen had been personalised. As noted, one person has chosen to paint their room a different colour. This was being arranged. Leighton House was seen to be very homely throughout. The premises were also clean. A cleaning rota was seen to be in operation. The bathroom carpet was stained. It was reported that it had been replaced since the last inspection but that the same problem had arisen. Some new flooring had been purchased and was about to be installed. Leighton House DS0000060129.V322299.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are competent and skilled, promoting the quality of care. Appropriate recruitment and selection procedures are generally followed, although service users may have been put at unnecessary risk by one recruitment decision made since the last inspection. Arrangements are in place which help to ensure that staff have the training required to support the people living in the home. EVIDENCE: Service users were positive about the staff team, saying that they were ‘nice’ and that ‘they care for me well’. They also indicated that staff were good listeners. Staff spoken with were able to demonstrate a good understanding of service users’ needs. The manager described plans to develop the role of seniors in the organisation to take on more responsibility. This will include conducting supervision meetings once they have received appropriate training. Leighton House DS0000060129.V322299.R01.S.doc Version 5.2 Page 19 Records and discussion provided evidence of good progress being made towards supporting staff to achieve NVQs in health and social care. The staffing file for a person who had joined the team since the last inspection was checked. This included necessary documentation and information. A suggestion was made to amend the application form to make it clear to candidates that they need to give ‘to’ and ‘from’ dates by month rather than just by year. Some staff had started on a PoVA-First basis. The manager said that a risk assessment is completed and put on file, with limitations on their role until the full CRB is in place, but that these would now have been removed from staffing files the CRB certificates having been received. CSCI was informed of a staffing issue in 2006. The staffing file in question was checked and there was a discussion about the documentation completed by the person when applying and also received by the home during the recruitment process. Whilst it is for the service provider/manager to decide whether a person is fit to work in the care setting, the inspector expressed significant concerns about the judgement that had been reached on this occasion given the information available. The issue had been resolved by the time of the inspection. A policy about staff induction and probation was seen, dated March 2006. There are also recent policies about training and supervision. Individual training profiles were being put together, along with a training matrix, in order to give a clearer idea of training received and required. Records provided evidence that the majority of staff were up to date with most areas of mandatory training. Some people had been identified as needing food hygiene and moving & handling training. This had been booked for Spring 2007. Fire training for the whole team had been arranged for February 2007. First aid was also being sourced for some people who needed updates. As noted, there was evidence of most staff undertaking training in adult protection and the safe handling of medication as well as accessing NVQs in health and social care. It was reported that training about a particular condition was being sourced, as relevant to the needs of service users supported in the home. Staff spoken with expressed satisfaction about training provided by the service. Leighton House DS0000060129.V322299.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is competent and experienced, promoting positive outcomes for service users. A good range of measures are in place which help with monitoring and improving the quality of the service. This includes seeking service users’ views. Systems are in place to promote the health and safety of staff and service users, although there is potential for some improvement in this area. EVIDENCE: During the original registration process the manager provided a certificate as evidence of achieving the Registered Manager’s Award in April 2003. She also has a HNC in Caring Services (managing care), which was agreed at the time Leighton House DS0000060129.V322299.R01.S.doc Version 5.2 Page 21 as meeting the criteria for qualifications in care. The manager said that she plans to take further courses in the future to update her knowledge and skills. The manager has acted as an NVQ assessor and attended a considerable number of other relevant training courses. She has been in a managerial post working with adults with learning disabilities since 1997. Prior to this she worked in less senior roles in the sector. Staff spoken with felt that the home was well run. It was reported that there are plans for the service to expand. A new brochure had been produced and a website was being launched. Quality assurance was discussed. Records were seen of service users’ meetings. These provided evidence of wide ranging and open discussion, with service users able to speak up and of action being taken as a result. The service has an audit plan, consisting of a programme of checks on different areas of operations such as training, care planning and health & safety. The inventory for one service user appeared to be up to date. However, the other service user’s inventory appeared not to have been updated since 2004. This should be done as part of ensuring that it is clear who owns which items, particularly in respect of larger items such as electrical equipment. Staff spoken with felt that their health and safety was looked after. Staff receive training about health and safety. A range of environmental risk assessments were seen to be in place. There is a monthly environmental audit. The system for reporting and addressing more urgent maintenance issues was also described and examples given. The fire log provided evidence of routine fire safety checks being carried out at suitable intervals. The following observations were made regarding health and safety: • • • A smoke alarm could be fitted in the office. A gas safety check was said to have been done in January 2006, although no paperwork could be found. It was agreed that in any case another safety check was now due. No routine checks on the safety portable appliances were being carried out. Most services carry out PAT testing approximately annually in addition to routine visual checks of appliances/plugs. The nighttime cover arrangements had changed. Instead of there being a staff member sleeping-in there was a person based in the adjoining property (a care Leighton House DS0000060129.V322299.R01.S.doc Version 5.2 Page 22 setting also run by the organisation). A monitor was in use for the service users to summon assistance if necessary. It was reported that the service users had practiced using this and were happy with the arrangement. Service users confirmed that they knew how to summon help and felt comfortable with the system. Some risk assessments were in place about the people living in the home being alone at times during the day for a particular number of hours. However, there was no risk assessment specifically covering issues related to the new nighttime arrangement. This should be done as part of formally documenting and assessing as thoroughly as possible the risks that may be presented and considering whether existing strategies for managing and minimising these are sufficient. Leighton House DS0000060129.V322299.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 2 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 2 35 3 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 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 2 x Leighton House DS0000060129.V322299.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA6 YA7 YA19 Good Practice Recommendations Continue to investigate the principles of ‘person-centred care planning’ and the tools available. Note the points made about service users’ finances in the text. Ensure that procedures are followed and full and complete records kept. Ensure that all healthcare appointments (including chiropody) are entered onto the record in order that these are complete. Investigate ‘health action planning’ (the principles and the templates available, including locally devised versions). Aim to implement this. Consider rephrasing some parts of the policy on prevention of abuse as described in the text. Consider modifying the application form to make it clear to candidates that they need to give ‘to’ and ‘from’ dates by month rather the year. Ensure that service users’ inventories are kept up to date, DS0000060129.V322299.R01.S.doc Version 5.2 Page 25 4 5 6 YA23 YA34 YA41 Leighton House 7 YA42 particularly in terms of larger items such as electrical equipment. Implement the three bullet points made in the text about health & safety. Conduct a risk assessment in respect of the new arrangements for nighttime support/cover, as discussed in text. Leighton House DS0000060129.V322299.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Leighton House DS0000060129.V322299.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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