Inspection on 09/07/07 for Life Works Community Ltd

This inspection was carried out on 9th July 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 found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Life Works Community Ltd 09/05/06

Life Works Community Ltd 26/04/05

Life Works Community Ltd 11/08/04

Life Works Community Ltd 23/06/04

Similar services:

Prinsted

Elizabeth House

Kenward House

Boons Park

Winthrop Hall

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

CARE HOME ADULTS 18-65 Life Works Community Ltd The Grange High Street Old Woking Surrey GU22 8LB Lead Inspector Pauline Long Unannounced Inspection 9th July 2007 09:30 Life Works Community Ltd DS0000059060.V339507.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 Life Works Community Ltd DS0000059060.V339507.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. Life Works Community Ltd DS0000059060.V339507.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Life Works Community Ltd Address The Grange High Street Old Woking Surrey GU22 8LB 01483 757572 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) enquiries@lifeworkscommunity.com Life Works Community Ltd Barnaby Giles Guthrie Care Home 24 Category(ies) of Past or present alcohol dependence (24), Past or registration, with number present drug dependence (24), Mental disorder, of places excluding learning disability or dementia (24) Life Works Community Ltd DS0000059060.V339507.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. From time to time the home may admit people over the age of 65 years Of the 24 service users, up to 4 may be accomodated for a detoxification programme, which requires nursing intervention. 9th May 2006 Date of last inspection Brief Description of the Service: Life Works Community Ltd is situated in The Grange, a grade ll listed building in the Old Woking area of Surrey. The property is set in two acres of mature gardens. The property consists of 7-shared occupancy bedrooms suitable for meeting the needs of service users with substance addictions, compulsive behaviours, trauma, co-dependency and dual diagnosis (addiction and depression/anxiety). Suitable measures have been taken to ensure service users privacy at all times and CCTV cameras are utilised to monitor the external areas of the property. The fees at the home range from £485 ponds per day to £ 785 pounds per day. Life Works Community Ltd DS0000059060.V339507.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 09.30 and was in the service for 5.5 hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s owner or manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the services and other people seen during the inspection or who responded to questionnaires that the Commission had sent out. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. The CSCI would like to thank the clients, the home manager and staff for their hospitality, assistance and co-operation during the site visit. What the service does well: What has improved since the last inspection? The homes assessment process has been improved, with further staff being employed to ensure more thorough care needs assessments are being undertaken. Life Works Community Ltd DS0000059060.V339507.R01.S.doc Version 5.2 Page 6 Morning clinical meetings have been introduced in order to give additional time to evaluate the client’s progress. Staffing hours have been increased in respect of qualified nursing staff. The staff have gained more experience in and a greater understanding of the Local Authorities Multi Agency Safeguarding Adults Procedure. New furniture has been bought for the communal sitting room. New carpets and redecoration has been undertaken in various areas of the home, providing a more pleasant environment for the clients. The kitchen has undergone a refit making it easier for the staff to keep it clean. The garden has been cleared of overgrowth and a wildflower meadow has been planted. New staff job profiles and a new appraisal system has been developed. New roles have been created in the home in order to divide up responsibilities. A Quality Assurance system has been developed and implemented in the home with a view to seeking the views of clients and other stakeholders. 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. Life Works Community Ltd DS0000059060.V339507.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 Life Works Community Ltd DS0000059060.V339507.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 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective clients are only admitted to the home following a comprehensive assessment of their needs. EVIDENCE: Three of the client’s files and care needs assessments were sampled. Assessment forms as well as a number of other records and checklists had been completed. The care needs assessments covered various issues, for example, mental health, medical health, dietary, trauma and abuse issues and other potential areas of concern. The manager stated that a number of professionals would be consulted with, prior to accepting a resident for treatment. Discussions indicated that all of the client’s needs may not be identified at the onset of treatment and therefore daily assessments would be carried out in clinical meetings and would be ongoing. The manager stated that more staff had been employed in order to ensure the admission process was improved, and that all of the pre assessment documentation would be in place prior to admission to the home. Discussions were had with some of the client’s and they confirmed that comprehensive assessments were carried out prior to their admission to the home and through out their stay. Life Works Community Ltd DS0000059060.V339507.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 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Client’s health and social care needs are well met. They are treated with respect and their privacy and dignity is promoted. EVIDENCE: All of the clients files sampled contained a care plan. The document would identify an over view of the clients aims and goals. As discussed in the previous section of this report, all of the clients, needs/goals may not be identified at the onset of treatment and may become increasing clearer as treatment progresses. In this respect a client’s progress would be discussed on a daily basis between a client and the nursing/clinical staff responsible for their care and care plans would be amended to reflect the changes. Clients confirmed that these meetings were held and documented. Minutes of these meetings were available but were not sampled. The clients discussed how the staff supported them in respect of their decisionmaking abilities. They commented that they each had a primary counsellor, who they could relate to. They also commented that the group support meetings were helpful and that it was very useful to get input from their peers. Life Works Community Ltd DS0000059060.V339507.R01.S.doc Version 5.2 Page 10 Discussions with the clients and staff, evidenced that clients concerns and choices were listened to during the weekly meetings and in one to one sessions. Examples and evidence were supplied in respect of client’s views being listened to and acted upon. The homes risk assessment tool was quite comprehensive. It was a tick chart format and was used for generalised risks. However on one risk assessment the reader was not clear as to whether or not any risks had been identified, as every box had been ticked. This was discussed with the Nursing Manager and Registered Manager at the time, they agreed that the particular risk assessment was not clear enough and that the issue would be addressed. Due to the nature of the service provided at the home and the potential risks to the clients, the clients are not permitted to lock their bedroom doors. They stated that they were aware of this restriction prior to being admitted to the home and understood why it was necessary. Life Works Community Ltd DS0000059060.V339507.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): 11,12,13,14,15,16,17 People who use the service experience excellent quality outcomes in this area. The clients are encouraged and enabled to maintain fulfilling lifestyles in the home, and engage in appropriate leisure activities. They are encouraged and enabled to makes choices in their lives and meal times are a positive experience for them EVIDENCE: Standards 12 and 13 do not apply to this service due to the nature of the short term and the specific nature of the treatment provided. The manager, however explained that all of the clients are strongly encouraged to participate in peer support networks following treatment. The home provides a service to clients from all over the world. Due to the nature of the service treatments are often for a brief period, therefore clients do not have time to develop strong links. As discussed earlier in this report comprehensive risk assessments are completed and in some cases result in wide ranging restrictions on the clients in respect of leaving the home. Clients commented, that they may visit local attractions at weekends, for example to Life Works Community Ltd DS0000059060.V339507.R01.S.doc Version 5.2 Page 12 visit a place to practice their faith, a local art gallery, a library or restaurant. The clients have the use of a tennis table, gym equipment, a piano, croquet equipment, badminton equipment and have access to an extensive library. Families are encouraged to attend a non-residential family workshop and are encouraged to visit their relative for two hours at the weekend. Clients commented that privacy and dignity was promoted and respected, and that they were informed of various restrictions before being admitted to the home: for example shearing a bedroom and not having keys to lock their bedroom door. Clients also commented that the staff were polite, courteous and respectful. The manager commented that whilst privacy is respected and promoted, clients at risk of self harm may require additional monitoring. Treatment and activities programmes are arranged around a strict routine and clients do not have a choice as to whether or not they attend, they must attend them. Again clients confirmed that they had been advised of this prior to admission. A dietician is employed by the home to oversee the treatment programmes for those clients with an eating disorder, and programmes are put in place to ensure that they receive a balanced diet, and are supported at mealtimes. Clients spoken with commented that whilst meal times were difficult for them, they understood the need for the structured programme. The menu was sampled and evidenced a well balanced, varied and apprizing diet. Residents commented that the food was like “eating in a restaurant” and that there was always plenty to eat and drink with snacks available through out the day. Discussions were had with the chef in respect of the residents particular dietary needs their likes and dislikes. He demonstrated a good understanding of these. Life Works Community Ltd DS0000059060.V339507.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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The staff have a good understanding of the clients physical, emotional and health support needs, this was evident from the positive interactions and relationships observed. Medication procedures must be more robust, in order to ensure that medication records are up to date and accurate. EVIDENCE: On the whole the clients at Life Works Community do not require and support with their personal care. Particular support may be required for those clients with a particular need in this respect. Clients spoken with commented that this support was offered in a sensitive, dignified and respectful manner. Healthcare at the home is given a high priority. The home retains the services of a private General Practitioner, and a private Psychiatrist. Several qualified registered nurses and a team of psychotherapists are employed to work at the home. Clients records clearly identified any health care and medical support required. The manager commented that the General Practitioner would assess each client on admission and would monitor their progress through out their stay. The clients spoken with confirmed this. Life Works Community Ltd DS0000059060.V339507.R01.S.doc Version 5.2 Page 14 Several of the clients require medication. The manager commented that due to the nature of the service provided and the associated risks, none of the clients would be permitted to keep and administer their own medications. Risk assessments in this respect were evident. Procedures in respect of the storage, administration and recording of medication were sampled. The storage was observed to be good, with general and controlled drugs stored appropriately and safely. Medication record sheets were checked and on the whole were found to be well documented with no gaps in signatures noted. However, it was noted that one of the two staff signatures was omitted from the controlled drugs register. This was discussed with the Nurse Manager at the time. She confirmed that she had conducted the medication check that morning and that it was her error. This was addressed immediately. The home has developed and implemented a policy and procedure in respect of invasive treatments and the management of epileptic seizures. This was sampled and found to be satisfactory. One practice session in respect of resuscitation and defibrillation equipment has been undertaken since the last inspection. This was discussed with the Nurse Manager at the time, she stated that she was going to arrange for the team to attend a training course in respect of resuscitation and that further practice sessions would be undertaken. Discussions were had with the clients in respect of the health care services provided at the home. They were complimentary about the service provided and had no concerns about their treatment. A requirement has been made in respect of these areas. Please refer to page 27 of this report. Life Works Community Ltd DS0000059060.V339507.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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The clients are protected by the homes policies, procedures and practices around concerns, complaints and protection. EVIDENCE: No complainants have contacted the Commission with information concerning a complaint made to the service since the last inspection. The home has received 15 complaints in the last twelve months, three of these complaints were upheld. Evidence seen indicated that the complaints had been investigated under the homes complaints procedures and satisfactorily resolved. Clients commented, that they were aware of the complaints procedure, and if they had any reason to complain, they would speak with the manager. The homes complaints procedure has been reviewed and amended to make it more user friendly. The manager commented that he facilitates weekly feedback meetings to enable the clients to raise any concerns. Clients confirmed this and commented that these meetings were very helpful. The homes Safeguarding Adults Procedures have been reviewed and amended in order to reflect the Local Authority Procedures. The manager commented that the home has been proactive in identifying clients who may have been abused prior to admission to the home. In this respect three referrals have been made under the local authority multi agency Safeguarding Adults procedures. Meetings have been held in this respect of these referrals and the issues have not been taken forward for investigation. Life Works Community Ltd DS0000059060.V339507.R01.S.doc Version 5.2 Page 16 Discussions were had with the staff on duty and scenarios put to them in respect of the home’s safeguarding adults and complaints procedures. Staff interviewed demonstrated a good understanding of the policies and procedures. The staff group have undertaken safeguarding adults training as evidenced in the training records. Life Works Community Ltd DS0000059060.V339507.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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is clean, hygienic and safe, and provides a high standard of accommodation for the clients. EVIDENCE: The home provides a high standard of accommodation for the clients, and improvements have been made since the last inspection. Some re-painting and re-carpeting is being undertaken. New sitting room furniture has been bought, which provides a more pleasant environment for the clients. Clients share bedrooms in groups of two or three, and those spoken with said that it was not a problem to share a room and that they had been advised of this prior to admission. They also commented that their rooms very comfortable. The kitchen is undergoing a refit which will make it easier to keep clean and orderly. Life Works Community Ltd DS0000059060.V339507.R01.S.doc Version 5.2 Page 18 A requirement was made at the previous inspection in respect of the gym equipment. It was noted that this equipment was still being kept in the homes dining room. Discussions were had with the manager in this respect. He stated that meetings had been held and plans drawn up to build a garden house, in order to provide a separate place for the clients to exercise. The plans in this respect were sampled. The manager stated that he was awaiting the planning permission and funding for this project. There is a large garden for the clients use, with a patio area with seating and tables. The garden has been cleared of overgrown areas and a wildflower meadow has been planted. Several clients were observed using and enjoying the garden on the day. The home was clean, tidy and hygienic. The manager commented that he was in the process of developing an infection control policy and procedure. Life Works Community Ltd DS0000059060.V339507.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled, well supervised and in sufficient numbers to support the people who use the service. Improvements are required in the homes recruitment procedures to ensure the continued protection of the clients. EVIDENCE: Staff files sampled, and work based observations evidenced that the home employs a diverse staff group. It was noted that staffing levels were adequate for the dependency levels of the clients. The manager stated that there had been difficulties in the past year with staff turnover. He was confident however that this area had been addressed and that agency usage at the home was minimised. The homes recruitment practices were sampled. Three staff files were sampled and two of them had the all of the required documentation in place, with evidence of CRB (Criminal records) or POVA (Protection of Vulnerable Adults) checks. One had only one written reference and no CRB or POVA checks were present. This shortfall was discussed with the manager at the time. Discussions were had about the problems the home was experiencing in respect of the Criminal Records Bureau, and the length of time it was taking Life Works Community Ltd DS0000059060.V339507.R01.S.doc Version 5.2 Page 20 for clearances to come through. In respect of this particular member of staff, he stated that she had worked at the home as an agency member of staff for some time, and was in the process of being recruited by the home. He produced a CRB and POVA check supplied to him by the agency. Discussions were had in respect of these documents not being portable between organisations. He was reminded of the requirement for all references and clearances to be in place before this, or any other member of staff is fully recruited to the homes staff team. The manager stated that the member of staff involved would remain an agency member of staff until all references and checks had been received. The manager discussed the need to improve the homes staff application form in order to ensure equality and diversity issues are explored. Discussions were had with staff, who, talked about their job roles and responsibilities. Work based observations evidenced competent and confident staff carrying out their various tasks. Staff discussed some of the training they had undertaken. Training records demonstrated that statutory and various current good practice training had been undertaken since the last inspection for example: induction, manual handling, health and safety, adult protection, fire safety, food hygiene and roles and responsibilities reporting and recording. The manager stated that twelve of the staff are undertaking a Masters degree in either counselling or psychology and that eight of the staff are Registered Nurses. Discussions were had in respect of the requirement for unqualified staff to undertake an NVQ qualification. Staff also discussed the regular team meetings and one to one supervision meetings they had with a manager or a senior member of staff. Records in this respect were sampled and evidenced one to one meetings were taking place on a regular basis. A requirement has been made in respect of these areas. Please refer to page 27 of this report. Life Works Community Ltd DS0000059060.V339507.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The clients benefit from an open and inclusive management approach to the running of the home and their views are listened to and acted upon. Improvements are required in respect of the manager’s qualifications. The health, safety and welfare of the clients and staff are promoted and protected. EVIDENCE: The manager has worked at the home for just under 2 years. He has a Masters degree in business administration. He has registered to undertake an NVQ 4 ( National Vocational Qualification) in care. Discussions were had around a the Registered Managers award. He stated that some confusion was caused at the last inspection in respect of him having registered to undertake the Registered Managers Award. He has not yet undertaken this award. Life Works Community Ltd DS0000059060.V339507.R01.S.doc Version 5.2 Page 22 The management approach to the running of the home is open and inclusive. Clients and staff commented that the manager was very approachable and supportive. Direct observations evidenced that clients and staff appeared to be relaxed and confident in his company. The home has developed an internal Quality Audit system, which is primarily based on resident feedback. Clients discussed the regular meetings held at the home, where they are encouraged to express their views as to the quality of the service provided. Several of the written feedback forms were sampled and on the whole evidenced satisfaction with the care provided at the home, for example: “ I was made to feel at home”, “ Thank you for all the effort you have put in”, “I remember being treated with respect”, staff are kind and considerate and “the food is akin to using a restaurant every day”. Discussions were had with the manager in respect of seeking the views of other stakeholders and professionals involved with the home. A requirement was made at the previous inspection in respect of recommendations made by the fire service. These recommendations have been actioned. Training in respect of fire procedures, moving and handling and food hygiene are up to date. Health and safety checks are carried out with clear and accurate records kept. The home has undertaken extensive risk assessments of the building and a CCTV system has been installed to ensure the health safety and wellbeing of all. A requirement has been made in respect of these areas. Please refer to page 27 of this report. Life Works Community Ltd DS0000059060.V339507.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 4 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 X LIFESTYLES Standard No Score 11 3 12 N/A 13 N/A 14 4 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 2 X 3 3 3 X X 3 X Life Works Community Ltd DS0000059060.V339507.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 YA20 Regulation 12(10(a) 13(2) Requirement Medication procedures and practices must be more robust, in order to ensure that medication records in respect of controlled drugs are signed by two appropriate members of staff. The recruitment and selection procedures must improve. The manager must ensure that he has a clear understanding of the National Minimum Standards, and the Care Homes Regulations (as amended 2006). The home must obtain two written references and POVA First clearances for all staff prior to them starting work. The manager must register to undertake the Registered Managers Award, in order to ensure that he has the required qualifications, skills and knowledge, necessary for managing the care home. Timescale for action 09/08/07 7. YA34 19 09/08/07 3. YA37 9(2)(b)(i) 09/09/07 Life Works Community Ltd DS0000059060.V339507.R01.S.doc Version 5.2 Page 25 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 Life Works Community Ltd DS0000059060.V339507.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Life Works Community Ltd DS0000059060.V339507.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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