Inspection on 03/05/05 for Libury Hall

This inspection was carried out on 3rd May 2005.

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 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

Libury Hall 18/04/07

Libury Hall 31/07/06

Libury Hall 07/02/06

Libury Hall 13/12/04

Libury Hall 29/06/04

Similar services:

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

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

CARE HOME ADULTS 18-65 Libury Hall Gt Munden Nr Ware Hertfordshire SG11 1JD Lead Inspector Julia Bradshaw Unannounced 03.05.05 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Libury Hall i52 s19448 Libury Hall v224243 030505 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Libury Hall Address Gt Munden Nr Ware Hertfordshire SG11 1JD 01920 438224 01920 438887 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs A Schorr Angela Smith Care Home 37 Category(ies) of LD LD Learning disability - 37 registration, with number LD(E) LD(E) Learning disability - over 65 - 37 of places MD MD Mental disorder - 37 MD(E) Mental disorder - over 65 Libury Hall i52 s19448 Libury Hall v224243 030505 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 03.05.05 Brief Description of the Service: Libury Hall comprises of a large detached House and five cottages located to the rear of the main house. The main house has been adapted and converted into providing 17 single bedrooms and two double rooms. There are four further bedrooms on the ground floor, with adequate bathrooms and toilet facilities provided on both floors. The main kitchen, laundry and offices are located on the ground floor. There are several large communal areas located throughout the ground floor.The cottages each provide a sitting/dining room, kitchen, bathroom, toilets and two or three bedrooms.The home is located in a rural position surrounded by farmland and the village of Great Munden is approximately half a mile away. The home provides transport on a daily basis, for service users, to embark on shopping and social trips to the nearby towns of Hertford or Ware. Libury Hall i52 s19448 Libury Hall v224243 030505 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced inspection of the inspection year and took place over one day. The majority of time was spent talking to service users, and staff. Some time was also spent in the office looking at Service Uer Plans, risk assessments, complaints, staff training, and staff files. Discussions were held with the Deputy manager John Murphy who was representing the manager in her absence. Service users and staff were very welcoming. This was generally a positive inspection, and the majority of the standards were met. Requirements were made in relation to medication, the environment and staff supervisions. What the service does well: Libury Hall has provided a safe and familiar environment to service users who have had chronic mental health needs and service users clearly see it as their home and have endeavoured to have ownership over some aspects of their lives. Staff observed interacted with service user in a professional and a caring manner and appeared to have a wealth of knowledge in relation to individual needs. Staff work tirelessly to maintain a homely and comfortable environment for service users although there is a constant struggle to maintain the buildings and keep all areas in a good state of repair due to the age of the property and the mis-use by some service users. The new registered manager has worked hard to implement new policies and procedures since her appointment in 2004 and has improved and developed several areas of the service, including service user plans, staff training risk assessments and quality assurance. Libury Hall i52 s19448 Libury Hall v224243 030505 stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Some areas of the service still need to improve to ensure that all service users have the opportunity to exercise their full rights and opportiunities. There was a lengthy discussion with the deputy manager regarding the current restrictions on some service users regarding smoking and also the arrangements of mealtimes. Both aspects of the service are inherent issues and should be reviewed regularly. Decisions that restrict service user liberties must be recorded on the service user care plan and reviewed regularly. The current medication procedures regarding homely remedies should be reviewed and actioned accordingly. A full pharmacy audit should be conducted to establish and confirm the current practices are in line with current legislation and meet the required standards of CSCI. There is an on going issue relating to the use of window restrictors within the home. There was a requirement made in 2004 that all windows should have either a window restrictor fitted or a risk assessment completed. Currently there are still some windows that are still without either a risk assessment or restrictor fitted. The manager needs to ensure that all senior staff provided staff with a minimum of six supervisions a year. There are some areas of the home that require attention in relation to maintenance and repair, which have been identified in the main body of the report. Libury Hall i52 s19448 Libury Hall v224243 030505 stage 4.doc Version 1.30 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Libury Hall i52 s19448 Libury Hall v224243 030505 stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Libury Hall i52 s19448 Libury Hall v224243 030505 stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,4. The home carries out a comprehensive and detailed system of assessment for all service users. The service users and staff create a welcoming and inclusive atmosphere. Information provided to the service user about the home and its terms is currently being updated and will soon provided a more “user friendly” document in order for service user to make an informed choice about where to live. EVIDENCE: The home’s Service User Guide is currently being updated and will be available in a more user friendly format before the next inspection takes place. The manager will also be updating the Statement of Purpose to reflect the current changes. All current and prospective service users will be provided with a copy. The content is suitable to meet individual needs. The Statement of Purpose requires minor amendments. Full assessments of each service users needs and aspiration 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. Libury Hall i52 s19448 Libury Hall v224243 030505 stage 4.doc Version 1.30 Page 10 The home also receives and seeks external specialist support to meet the individual service users needs. Whole life reviews occur within the home to support the service users in achieving and reviewing individual needs, goals and aspirations. The admissions procedure to the home includes trial visits for the service users to make an informed choice about where to live. A contract is then drawn up between the home and the service user. The contract includes the terms and conditions within the home and the rights of the service user. Libury Hall i52 s19448 Libury Hall v224243 030505 stage 4.doc Version 1.30 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8,9,10 Generally individual needs and choices within the home are being promoted to encourage and empower user self-determination. Service user plans do not fully reflect the service users needs. Service users have the opportunity to contribute to decisions taken within the home. Service users are at risk from issues relating to health and safety. EVIDENCE: All service users have an individual care plan and an allocated key worker to support them within the home. Individual daily notes and guidelines for the service users where observed within the home. The new manager is in the process of introducing a new care planning process in order to create a “working style” document. The staff have worked hard to implement this new system and should complete this task before the next inspection takes place. Libury Hall i52 s19448 Libury Hall v224243 030505 stage 4.doc Version 1.30 Page 12 All service users are supported within the Care Programme Approach or Whole Life Review framework 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. Within the home each service user is encouraged to partake in some daily living tasks, although due to the internal structure of the home this can prove problematic as both the kitchen and laundry areas have industrial rather than domestic style equipment which makes individual participation difficult to promote. All information within the home is handled with care and respect. All personal notes and files detailing information on the service user are locked away. Risk assessments are identified and completed on an individual and generic basis. However some of these risk assessments require updating and reviewing. Also the current risk assessments relating to window restrictors require completion. Libury Hall i52 s19448 Libury Hall v224243 030505 stage 4.doc Version 1.30 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,13,15,17 Personal development opportunities are encouraged for all service users ensuring interactions with the outside community are encouraged, although this can prove problematic due to the rural location of the home. Individual rights and opportunities are recognised and supported, where possible. Restrictions on service users independence and rights are on occasions compromised. Personal and sexual relationships are supported in a mature and professional manner. Service users are provided with a varied and wholesome diet. EVIDENCE: Libury Hall i52 s19448 Libury Hall v224243 030505 stage 4.doc Version 1.30 Page 14 The majority of service users attend the day centre, which is located within the grounds of the home, which provides a variety of activities, suitable to people’s individual needs and aspirations. Discussions with the service users determined that they have a variety of choice within the day centre. Access to transport is through two “on-site vehicles”. 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 personal and self help tasks were observed throughout the inspection. All service users are encouraged and supported to maintain links to the local community. However, this can prove problematic, as the home is located in an isolated location outside the town of Ware. Although staff do organise regular trips to both Hertford and Ware for shopping and leisure activities. During the inspection, staff and service users were observed to interact equally with one another. The staff team endeavour to promote routines within the home in order to maintain service user’s independence. However, there are a high proportion of service users who have been living at the home for many years and have become quite “institutionalised” in their attitude. This has created a dependency on staff often carrying out tasks on their behalf. Also some service users are becoming older and frailer and therefore require more staff support. Service uses are unrestricted in movement around the home, with the exception of the main kitchen area and laundry room. Menus are rotated on a four weekly basis and have been reviewed since the last inspection took place. Generally the feedback from service users is that the meals are both adequate in size and wholesome. However, there is the ongoing debate with the manager from the inspectors regarding the current arrangement for serving the main meals within the dining room. This arrangement involves service users “queuing up” for their meals to be “dished out” from a main trolley. This creates a very institutionalised image and restricts service users choice and individuality. There was a suggestion that meals are served up to the individual tables for service users to serve themselves. Libury Hall i52 s19448 Libury Hall v224243 030505 stage 4.doc Version 1.30 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18.19,20,21. The current medication practices and maintenance for medication are insufficient and inadequate. The ageing, illness and death of a service user is handled with respect and information recorded is accurate. Service users emotional and physical needs are being met adequately. EVIDENCE: The current arrangements for the storage and handling of medication are inadequate and do not meet the current standards as the cupboard that is currently used to store the bulk of the home’s medication is wooden and should be a metal cupboard. Also the storage of diazepam is inadequate and should be stored separately to ensure it is maintained safely. The manager must ensure that all “homely” remedies are authorised for all service users who require them. This requires the G.P. to list the names of each service user against each homely remedy. Controlled medication should be maintained and recorded separately. A hardback book should be provided, with numbered pages, which is bound. The last pharmacy visit was carried out on the 10/4/05. Libury Hall i52 s19448 Libury Hall v224243 030505 stage 4.doc Version 1.30 Page 16 There were some gaps in the recording of controlled medication and the manager must ensure that this situation does not re-occur .The manager has just implemented a medication audit, which should help prevent the aforementioned errors re-occurring. The home has a contract with Lloyd’s pharmacy in Bishop Stortford who supplies all medication in blister packs. The home has a system of “ double” signatures on all medication. All non-blister pack medication has “date of opening” recorded and there is a drugs fridge in use, which is maintained appropriately with daily temperatures, taken. The home has good links with the local community mental health team and local psychiatric services. All service users use one local G.P. surgery and accurate records are maintained regarding service users individual health needs. Libury Hall i52 s19448 Libury Hall v224243 030505 stage 4.doc Version 1.30 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 The complaints procedure within the home 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 detailed complaints procedure in place, which details that all complaints are responded to within 28 days. A record is maintained within the home of any 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. The complaints procedure requires updating to include the correct contact details of the CSCI. A detailed procedure is in place to ensure that service users are protected from abuse and harm. Staff receive suitable and adequate Protection of Vulnerable Adults (POVA) training. Staff employed within the home are all subject to enhanced Criminal Records Bureau (CRB). Staff personnel files were unable to be inspected due to not being held on site. Libury Hall i52 s19448 Libury Hall v224243 030505 stage 4.doc Version 1.30 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,27.28,30 The home is in need of some redecoration and works throughout, to ensure it functions as a homely, comfortable, safe environment for the service users. Individual bedrooms were personalised which promoted independence and choices and preferences for the service users. The service users health and safety is currently being compromised. EVIDENCE: There are some areas of the home that need some attention as they currently present as a health and safety risk to both service users and staff. The areas that require urgent attention include, the flooring in the downstairs corridor, which is currently stuck down with “sticky” tape. There is a large crack in the wall outside room 21. Door wedges must not be used in any circumstance and the manager must ensure all wedges are removed from the building. There are insufficient precautions taken in relation to ensuring that the upstairs windows are safe, as some windows have had their restrictors removed on the advice of the fire officer. This arrangement is unsatisfactory and all windows must be reassessed and where an unacceptable risk is identified window restrictors must be re-fitted. Libury Hall i52 s19448 Libury Hall v224243 030505 stage 4.doc Version 1.30 Page 19 All water temperatures were being delivered within safe limits and an accurate record is maintained. The maintenance person records all the fire checks and these were all being carried out on a regular basis. The last annual fire inspection was carried out in May 2004. The home has an annual insurance certificate that covers the period from 6/4/05 to 5/4/06. There is an annual renewals and replacement programme in place and the manager and handyperson are being pro-active in endeavouring to improve and enhance the environment for service users. Since the last inspection was carried out the home has benefited from new fire doors being fitted, new carpets laid and some internal decoration. One bathroom will have a replacement parker bath fitted. There is a plan to replace all the bedroom doors with a more appropriate style ensuring service users privacy is maintained. There was a discussion with both the deputy manager and the manager regarding the standard of outside lighting leading from the main house to the separate cottages. The manager stated that the land between these two buildings is not owned by Libury Hall and therefore there are limited options for improvement without the consent of the farm owner. Therefore, the manager has agreed, in the interim, that staff and service users who pass between the main home and the cottages when it is dark should carry adequate precautions to ensure their health and safety, a risk assessment should also be carried out. Libury Hall i52 s19448 Libury Hall v224243 030505 stage 4.doc Version 1.30 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,34,35,36 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 are held on site and were made available. Policies and procedures are in place to ensure the protection of service users. Staff supervision is infrequent. EVIDENCE: Staff spoken with during the inspection appeared very clear of their individual roles and responsibilities. The home has a loyal and long standing staff team that appear to have a good understanding of the current service users needs and abilities. Staff were seen to support the main aims and values of the home. All staff should receive a copy of the General Social Care Council Code of Conduct before the next inspection takes place. The home has clearly defined job descriptions and person specifications in place. All staff will or have received a series of mandatory training course in order for them to meet the complex needs of the service users. Libury Hall i52 s19448 Libury Hall v224243 030505 stage 4.doc Version 1.30 Page 21 The deputy manager is in the process of reviewing and assessing individual staff training needs with an external consultant. Recent training includes, food hygiene, medication and fire training. There is also training in POVA and Aspergers syndrome planned for June 2005. The deputy manager is currently in the process of creating a new training” matrix” in order to replace the existing system of recording, which is inadequate. The manager must ensure that all staff have mandatory training provided. There is currently only one member of staff who is doing NVQ level 2 but the manager is hopeful that more staff will be commencing NVQ training later on this year. The manager provides regular staff meetings but there was inadequate evidence to confirm that staff receive supervision on a regular basis. Libury Hall i52 s19448 Libury Hall v224243 030505 stage 4.doc Version 1.30 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39,42 The management within the home 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 to ensure that service users views underpin all self-monitoring, review and development of the home. The service users health and safety is currently being compromised. EVIDENCE: Service users spoken to during the inspection appeared to be extremely happy with the home 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 management approach of the home endeavours to create an open and positive atmosphere, staff and service users spoken to commented that they feel supported and feel the home is well managed. Libury Hall i52 s19448 Libury Hall v224243 030505 stage 4.doc Version 1.30 Page 23 A clear commitment is made to equal opportunities within the home, with staff and service users expressing positive views with regards to this. Adequate training is being provided to ensure all staff have the necessary underpinning knowledge to carry out their role effectively. The home is in the process of carrying out annual appraisals but supervision sessions appear inconsistent and need to be held more regularly. Quality assurance systems are in the process of being developed within the home in order to assure that the service users views underpin all selfmonitoring, review and development of the home. The deputy manager has recently completed a kitchen and medication audit and will have completed a care-planning audit before the next inspection takes place. Service user meetings occur within the home 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 within the home and 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. There are several issues regarding health and safety, which require urgent attention. The risk assessments relating to the window restrictors are incomplete and some service users safety is currently being compromised. The manager is arranging for the fire service to re-visit the home to advise and report on the current arrangements with regard to the risk of fire and evacuation procedures. There are some issues relating to the administration and storage of medication that require attention and further advice from the pharmacy Inspector. Door wedges were still being used and the manager was informed that this practice must cease immediately. Libury Hall i52 s19448 Libury Hall v224243 030505 stage 4.doc Version 1.30 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 x 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 3 3 3 Standard No 11 12 13 14 15 16 17 3 x 2 x 3 x 2 Standard No 31 32 33 34 35 36 Score 3 x x 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Libury Hall Score 3 3 2 3 Standard No 37 38 39 40 41 42 43 Score x x 2 x x 1 x i52 s19448 Libury Hall v224243 030505 stage 4.doc Version 1.30 Page 25 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. 2. 3. 4. Standard 6 9 20 20 Regulation 15 13(4)(c) 13(2) 13(2) Requirement All Service user plans must be completed. All individual and generic risk assessments must be completed. All homely remedies must be written up by the G.P. All medication must be stored appropriately and within a metal cabinet and fitted with rag bolts There must be NO gaps in the recording of medication. All controlled medication must be recorded in a hardbacked and bound book. The manager must dispose of all door wedges within the home. Doors must only be held open by devices approved by the Community Fire Safety Officer. The manager must carry out a full audit on all upstair windows and either fit window restrictors or complete a risk assessment. The flooring outside room 20 must be either repaired or replaced The large crack in the wall outside room 21 must be repaired. The manager must ensure that Timescale for action 31/7/05 31/5/05 21/5/05 31/5/05 5. 6. 7. 20 20 24 13(2) 13(2) 23(4)(c) (iii) 5/5/05 12/5/05 5/5/05 8. 24 13(4)(c) 11/5/05 9. 10. 11. 28 24 24 23(2)(b) 16(2)(c) 23(2)(b) 13(4)(c) 12/5/05 11/5/05 6/5/05 Page 26 Libury Hall i52 s19448 Libury Hall v224243 030505 stage 4.doc Version 1.30 23(2)(p) 12. 13. 36 6 18(2) 17(1)(a) schedule 3(3)(q) staff and service users have adequate lighting between the main home and the cottages. The manager must ensure that 6/5/05 staff receive regular supervision. The manager must implement a 31/5/05 system of reviewing the individual restrictions imposed on some servie users with regard to smoking and access to drinks and light refreshments. 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. Refer to Standard 15 20 Good Practice Recommendations The manager should review the current arrangments reagarding mealtimes and the current practice of service user queuing up for their meals The admissions policy should be forwarded to the CSCI. Libury Hall i52 s19448 Libury Hall v224243 030505 stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection 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 Libury Hall i52 s19448 Libury Hall v224243 030505 stage 4.doc Version 1.30 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!