Inspection on 19/09/06 for Leyland House

This inspection was carried out on 19th September 2006.

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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Leyland House 25/07/07

Leyland House 21/12/05

Leyland House 07/04/05

Leyland House 20/10/04

Leyland House 31/07/04

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Leyland House 22 Leyland Avenue St. Albans Hertfordshire AL1 2BE Lead Inspector Louise Bushell Key Unannounced Inspection 14:00 19 September 2006 th Leyland House DS0000019446.V304278.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 Leyland House DS0000019446.V304278.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 Older People and 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. Leyland House DS0000019446.V304278.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Leyland House Address 22 Leyland Avenue St. Albans Hertfordshire AL1 2BE 01727 763 707 01727 763 707 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) New Link Residential Homes Association Mr Keith Hung Mrs Sinikka Hung Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Leyland House DS0000019446.V304278.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 21st December 2005 Brief Description of the Service: Leyland House is an end of terrace property in a cul-de-sac in a residential area of St Albans, and provides a home for three service users who may be of either sex. The current people have been resident at Leyland House for between seven and twelve years. The home is domestic in size and character, having an open-plan living area, a kitchen and bathroom on the ground floor; three bedrooms, a toilet, a small office and a staff sleeping-in room on the first floor. There is a small area to the front for car parking and a rear garden with lawn and flowerbeds. There are local shops in the vicinity and the city centre is within walking distance. Public transport services are available nearby. The fee range was not available at this inspection. Leyland House DS0000019446.V304278.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place mid afternoon on the 19th September. The focus of the inspection was an unannounced key inspection. The evidence and information gathered for this inspection has been obtained from a variety of sources and involves direct contact with service users, families, staff, the pre inspection questionnaires, service user and relative surveys. Where information has remained the same from the last inspection, this has been carried forward to this report. This is an extremely positive inspection and the entire staff team should be commended for the efforts and commitment to the service users. What the service does well: The home has clear policies and procedures that are well organised, well maintained and accessible to all. The atmosphere throughout the inspection was calm and friendly, promoting a good relationship between staff and service users. Staff spoken with during the inspection were very complimentary of the management style within the home and the ethos of working openly, honestly and with a transparent approach appears to be effective. Three service users were present throughout the inspection and participated fully, giving clear indications that they were happy and relaxed within their environment. The home has a high ratio of staff to service users ensuring that individual and complex needs can be met. The home has an extremely stable staff team to promote continuity for the service users. All service users are supported within the Care Programme Approach framework and frequent reviews occur to ensure changing needs are continuously assessed and reviewed. The ethos within the home promotes that the care plans of each individual are owned by the individual, those service users spoken to during the inspection were aware of their individual care plans, one spoke of the support she receives from outside services. The home is vibrantly decorated and the service users have made the choices for decoration collectively. Service users meetings occur which are recorded and details service users choices and suggestions which have been acted upon The home has robust policy and procedures in place to support the safe administration, storage and receipt of medicines. All staff receives training prior to being deemed competent to administer medication. All staff have received a series of mandatory training course in order for them to meet the Leyland House DS0000019446.V304278.R01.S.doc Version 5.2 Page 6 complex needs of the service users. Training includes Protection of Vulnerable Adults, food hygiene, risk assessment, challenging behaviour, first aid, mental health, personality disorder, epilepsy, foot care, loss and bereavement, feeding awareness, relating to people. 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. Leyland House DS0000019446.V304278.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Leyland House DS0000019446.V304278.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 & 5 Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. Prospective service users individual aspirations and needs are assessed and reviewed, enabling the service user and the home to continuously review the individual’s care package provided. Information provided to the service user about the home and its terms is suitable to meet their needs and therefore enables the service user to make an informed choice about where to live. Leyland House DS0000019446.V304278.R01.S.doc Version 5.2 Page 9 EVIDENCE: A comprehensive Statement of Purpose is held within the home and all current and prospective service users are provided with a copy. The Statement contains information for the service user to make an informed choice about where to live. The content is suitable to meet individual needs. Full assessments of each service users needs and aspirations are made before the service user moves into the home. The assessments carried out within the home are continuously occurring supporting and monitoring individual progress and needs identified. Qualified and competent people complete the assessments. The home also receives and seeks external specialist support to meet the individual service users needs. Whole life reviews occur to support the service users in achieving and reviewing individual needs, goals and aspirations. The admissions procedure includes trial visits for the service users to make an informed choice about where to live. A contract is then drawn between the home and the service user. The contract includes the terms and conditions and the rights of the service user. Leyland House DS0000019446.V304278.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 & 10 Quality in this outcome is excellent. This judgement has been made using available evidence including a visit to this service. Individual needs and choices are being promoted to encourage and empower user self-determination. Service users are supported to take risks as part of an independent life style, encouraging the completion of daily living skills and independence. Leyland House DS0000019446.V304278.R01.S.doc Version 5.2 Page 11 EVIDENCE: All service users have an individual care plan and an allocated key worker and co key worker to support them in the home. Individual daily notes and guidelines for the service users where observed within the home. All service users are supported within the Care Programme Approach framework and frequent reviews occur to ensure changing needs are continuously assessed and reviewed. The ethos of the home promotes that the care plans of each individual are owned by the individual, those service users spoken to during the inspection were aware of their individual care plans, one spoke of the support she receives from outside services. Each service user is encouraged to join in daily living tasks, for example being supported with meal preparation, washing up, laying the table, shopping. The staff and the service users have devised a rota, which following discussions with the service users, is effective and they enjoy being part of the running of the home. The home is vibrantly decorated and the choices for decoration have been made collectively by the service users. All information is handled with care and respect. All personal notes and files detailing information on the service user are locked away. Staff enable and support service users to take responsibility and actively manage risk as part of an independent live style. Staff support service users to make active decisions and choices regarding elements of risk in every day living, ensuring that they have accurate information to guide their decisions to inform them of the risks. A multitude of risk assessments are available that ensure risk is identified, minimised and management internally, seeking external remedies as required. Each risk assessment is reviewed and signed. Leyland House DS0000019446.V304278.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. Service Users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15 16 & 17 Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. Leyland House DS0000019446.V304278.R01.S.doc Version 5.2 Page 13 Personal development opportunities are encouraged for all service users ensuring interactions within the local community and that individual rights and responsibilities are recognised and supported. Service users are supported to maintain personal and family links, empowering service users rights, dignity and privacy. EVIDENCE: Service users attend a variety of different day centres and colleges accessing courses suitable to their individual needs and aspirations. Discussions with the service users determined that they have a variety of day activities to be involved with. Access to transport occurs with the use of local transport where appropriate support is provided to individuals. Staff support and encourage all service users to maintain and develop social, emotional, communication and independent living skills. The involvement of the service users in a variety of tasks was observed throughout the inspection. All service users are encouraged and supported to maintain links to the local community. The home is close to the city centre and is within a residential area of the city. The home values and seeks to reflect racial and cultural diversity of service users through celebration of, and awareness of different cultures, religions and festivities. During the inspection staff and service users were observed to interact equally with one another. Routines within the home promote service user independence. Service users are unrestricted in their movement around the home and are able to access all communal areas. Menus are offered on a flexible basis, with service users making choices over the meals daily. Service users are involved in meal preparation with appropriate support provided. All service users are provided with external nutritional advice and assessments and monthly weights are recorded. Meals observed were unrushed and relaxed. Direct feedback from service users determined that they are encouraged, supported and empowered to maintain positive family links and friendship, inside and outside the home. The inspector spoke directly to a parent of a resident who confirmed that the home welcomes visitors at all times and that they feel welcomed by all. The home maintains positive links with all family members seeking their input and support as appropriate. Leyland House DS0000019446.V304278.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. All personal and health care support is well maintained within the home ensuring individual needs, choices and preferences are met at all times. Service users are supported on an individual basis, with a care package tailored to meet their specific needs, ensuring that they receive personal support in a way they prefer and require. Leyland House DS0000019446.V304278.R01.S.doc Version 5.2 Page 15 EVIDENCE: All care provided is individual and tailored to each person, with service users needs, choices and preferences being promoted. Assessments and reviews are continuously completed ensuring that the approach adopted by the home is person centred and holistic to each service users needs. Service users needs are supported with all aspects of their physical and emotional health and receive adequate and appropriate input from specialists such as community nurses, consultants, GP, dentists, opticians and dieticians. Information and advice is provided to all services users regarding general health issues. The home has a robust policy and procedure in place to support the safe administration, storage and receipt of medicines. All staff receive training prior to being deemed competent to administer medication. The home uses Taylor’s pharmacy and has a good working relationship with them. Contracts are present between the pharmacy and the home and pharmacy inspections are carried out frequently. The home uses a Nomad Doset box system for safe administration. Records showed that correction fluid had been used on the Medication Recording Records. This was discussed at the time of the inspection. Detailed care plans are in place that refers to the individual needs, preferences and wishes. Care plans do not restrict the service users in any way. Where restrictions are imposed clear documentation is available and evident with consistent reviewing and support from a multi disciplinary team. Service users are supported with a named key worker system, feedback from service users determined that they have and maintain positive links with their key worker and that they are there to support them. Each service user is encouraged to maintain and develop individuality and style; this is reflective in personal appearance and their private space. A culturally diverse staff team ensuring specific needs can be met as required supports service users. The ethos of good practice ensures that staff ensure consistency and continuity of support through the key worker system, sound working relationships with families, friends and partners, including other professionals. Leyland House DS0000019446.V304278.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure is sufficient and adequate in order for the service users to feel that their individual views are listened too. Robust policies, procedures and training are in place to ensure service users are protected and safe. EVIDENCE: The home has a comprehensive complaints procedure in place, which details that all complaints are responded to within 28 days. A record is maintained within the home of complaints made, detailing actions and outcomes as necessary. All service users have been informed about the complaints procedure. This is also on display within the home. Robust procedures are in place to ensure that service users are protected from abuse and harm. Staff receive suitable and adequate Protection of Vulnerable Adults (POVA) training, which is currently occurring within the home. Staff employed within the home are all subject to enhanced Criminal Records Bureau (CRB). Staff files were fully inspected and determined that suitable checks have occurred on the recruitment of all staff. Leyland House DS0000019446.V304278.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 28 30 Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. Individual bedrooms were personalised which promoted independence and choices and preferences for the service users. Following redecoration the home presents well. Leyland House DS0000019446.V304278.R01.S.doc Version 5.2 Page 18 EVIDENCE: The home appears safe and appropriate to meet the needs of the service users living at the home. All service users have been actively involved in the choice of colours and furniture and carpets for the home. The home provides sufficient lighting, heating and ventilation. Each service user has a single bedroom, which is personal to each individual. Some of the rooms have been recently redecorated and the remaining rooms are due to be completed soon. Service users are offered a key to their room, where a key is not offered a risk assessment must be completed to determine limitations of service users rights. There is one main bathroom and a single toilet. The bathroom is on the ground floor. The entire bathroom has recently been replaced and now presents as a homely comfortable environment. Shared space is provided within the home. The kitchen has recently been refitted and presents as a homely, hygienic environment. The home was clean and hygienic throughout. Laundry facilities are domestic in style. A number of new items have recently been replaced and this includes new double glazed windows and doors, new nets and curtains, a new fridge freezer and redecoration in some areas. Leyland House DS0000019446.V304278.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 & 36 Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. The home is suitably staffed with well-trained individuals ensuring that at all times service users complex and changing needs can be met. Recruitment policies and personnel records must be held on site and be available at all times in order to establish robust procedures have been followed for the protection and safety of the service users. Leyland House DS0000019446.V304278.R01.S.doc Version 5.2 Page 20 EVIDENCE: Staff spoken with during the inspection appeared very clear of their individual roles and responsibilities. All staff have been in post between 4 – 10 years, offering a consistent approach for all service users. Staff were seen to support the main aims and values of the home. All staff have received a copy of the General Social Care Council Code of Conduct. The home has clearly defined job descriptions and person specifications in place. All staff have received a series of mandatory training course in order for them to meet the complex needs of the service users. Training includes Protection of Vulnerable Adults, food hygiene, risk assessment, challenging behaviour, first aid, mental health, personality disorder, epilepsy, foot care, loss and bereavement, feeding awareness, relating to people and valuing people. Training records are maintained within the home. All staff within the home have either completed or are working towards their NVQ 2 in care. The manager and the deputy have completed the NVQ 4 in care the Registered Managers Award NVQ 4. Recruitment practices within the home appear well structured. All policies and procedures relevant to the home must be on site at all times. See comments in the Conduct and Management of the home.Supervision and appraisal occurs within the home and staff felt that this was a valuable process. Leyland House DS0000019446.V304278.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. Service users live in a home which is run and managed by a person who is fit to be in charge of good character and able to discharge his or her responsibilities fully. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) 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, 38, 39, 41 & 42 Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. The management is secure and effective ensuring that changing needs of service users are met and that the home is running meeting its aims and objectives. Quality assurance systems are in the process of being implemented Leyland House DS0000019446.V304278.R01.S.doc Version 5.2 Page 22 to ensure that service users views underpin all self-monitoring, review and development of the home. EVIDENCE: Service users spoken to during the inspection appeared to be extremely happy and appeared to be relaxed in their environment. The relationship between the service users and the staff is well balanced with interactions observed being appropriate and supportive. The ethos and management approach of the home creates an open, positive and inclusive atmosphere, staff and service users spoken to commented that they feel extremely supported and they feel the home is well managed. A clear commitment is made to equal opportunities within the home, with staff and service users expressing positive views with regards to this. The service users appeared to benefit from this well structured and well run home. All staff and managers are adequately and suitably trained in order to meet the complex changing needs of the service users. Quality assurance systems are in the process of being developed in order to assure that the service users views underpin all self-monitoring, review and development of the home. The manager was able to discuss the systems that they are currently working towards. Residents meetings occur and minutes are taken. The service users spoken to felt that their views were listened to and considered. The minutes reflected the involvement of the service user within the home. All records are secure, were up to date and held in accordance with the Data Protection act 1998 ensuring that service users rights and best interests are safe guarded by the homes polices and procedures. Records regarding staff were not inspected and must be held within the home. Although it must be noted that staff have been in post for some time and previous inspections hane not raised concerns or issues in this area A requirement has not been made. Sound generic risk assessments were in place within home, with all external required safety checks occurring. There is a need to complete service user individual risk assessments regarding the use of hot water; a hand towel and soap dispenser must be erected in the bathroom. The legionella test certificate must be available for inspection. These requirements will enhance the health and safety of both the service users and the staff. Leyland House DS0000019446.V304278.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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT Standard No Score 37 3 38 3 39 3 40 X 41 3 42 2 43 x 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Leyland House Score 3 3 3 X DS0000019446.V304278.R01.S.doc Version 5.2 Page 24 No 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 YA42 Regulation 13(4) (c) • Requirement Individual and generic risk assessment for the health and safety management of hot water systems must be in place. A hand towel and soap dispenser must be fitted in the bathroom. A legionella test certificate must be available. Timescale for action 15/11/06 • • RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Leyland House DS0000019446.V304278.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. Leyland House DS0000019446.V304278.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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