Inspection on 06/06/06 for Lifestyles Care Home

This inspection was carried out on 6th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lifestyles Care Home 10/07/08

Lifestyles Care Home 20/07/07

Lifestyles Care Home 23/01/07

Lifestyles Care Home 14/12/05

Lifestyles Care Home 25/08/05

Lifestyles Care Home 15/02/05

Lifestyles Care Home 09/08/04

Lifestyles Care Home 30/09/03

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

CARE HOME ADULTS 18-65 Lifestyles Care Centre For Adults With Disabilities Weeland Road Eggborough Goole North Humberside DN14 0RX Lead Inspector Denise Rouse Key Unannounced Inspection 6th June 2006 09:30 Lifestyles Care Centre For Adults With Disabilities DS0000027965.V299210.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 Lifestyles Care Centre For Adults With Disabilities DS0000027965.V299210.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. Lifestyles Care Centre For Adults With Disabilities DS0000027965.V299210.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lifestyles Care Centre For Adults With Disabilities Weeland Road Eggborough Goole North Humberside DN14 0RX 01977 661492 F/P 01977 661492 Address 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) Lifestyles Care (Yorkshire) Limited Miss Jean Cronin Care Home 20 Category(ies) of Physical disability (20) registration, with number of places Lifestyles Care Centre For Adults With Disabilities DS0000027965.V299210.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th December 2005 Brief Description of the Service: Lifestyles Care Centre was originally a hotel, which has been converted into a care home with a nursing provision. It offers permanent and respite nursing care for adults with disabilities. The home is situated in Eggborough, a village 7 miles from Selby. Within quarter of a mile are a pub and some small local shops. Fees range upwards from £700.00 per week. Lifestyles Care Centre For Adults With Disabilities DS0000027965.V299210.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced site visit took place over seven and a half hours. A tour of the building was undertaken. A visitor, service users and staff were spoken with. Direct observation of the service users and staff was also undertaken. A pre inspection questionnaire was received and information from this was utilized. Documentation examined included four care profiles, medication charts, policies and procedures, kitchen records, accident and complaint records. The manager was available to assist with the site visit. Service user surveys were left for staff to assist service users to give their views about the care home if they wished. Two surveys were returned. What the service does well: What has improved since the last inspection? The home manager has implemented new policies and procedures within the home. She has undertaken responsibility to record maintenance checks relating to hot water temperatures within service users bedrooms and communal bathrooms, concerns are monitored and action taken to ensure safety. The named nurse and key worker system has been reviewed to ensure all service users have named staff on day and night duty overseeing their care. This enhances continuity of care for service users. A part time activities co-ordinator has now been appointed, who has in depth knowledge about each service users social history, ensuring activities are relevant to each service user. The home has commenced utilizing a self-employed handyman occasionally, to help maintain the building. The reception area has had a new carpet fitted, which enhanced this area, making it more pleasant for service users, staff and visitors. Medications were being handled and stored correctly; this protects service users and staff. Lifestyles Care Centre For Adults With Disabilities DS0000027965.V299210.R01.S.doc Version 5.2 Page 6 The two ground floor rooms (former toilet and store room) have been modernised to provide wheelchair access shower rooms. Work has commenced on a bathroom to improve water pressure and temperature control. 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. Lifestyles Care Centre For Adults With Disabilities DS0000027965.V299210.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 Lifestyles Care Centre For Adults With Disabilities DS0000027965.V299210.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 Quality in this outcome area was adequate. Service users aspirations and needs were assessed prior to the service user being offered a placement within the home; this ensures that the service users needs are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four service users were case tracked; one of the latest admissions to the home had evidence of a pre admission assessment within the care profile, this document contained basic information. The other three had been residing for a long time within the home; these documents were not available for inspection. In view of this it was not possible to be sure that all their needs could be met. The home manager had produced a new assessment document, which seemed very thorough, although this had not been used yet. This new document would be used to assess the needs of any new service user referred to the home to ensure that their needs were fully understood, and could be met. Lifestyles Care Centre For Adults With Disabilities DS0000027965.V299210.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6 7 9 Quality in this outcome area was adequate. Each service users had an individual plan of care; service users were assisted to make decisions about their lives, and could take risks whilst being adequately supported by staff. This judgment has been made using available evidence including a visit to this service. EVIDENCE: All service users needs were well known to staff, service users were seen to be assisted with dignity respect and kindness. Four service users were case tracked each had care plans and risk assessments in place. The content of these documents were adequate. All service users had care plans in place relating to activities. Service users who were able to make decisions about how they live their lives were supported sensitively by dedicated staff. Service users who could not communicate their wishes had input from their families. A team of named nurses and care staff ensured that service users Lifestyles Care Centre For Adults With Disabilities DS0000027965.V299210.R01.S.doc Version 5.2 Page 10 were treated, as they would have wished to be treated with dignity and respect. One service user who could not communicate verbally was known to love football and be a supporter of a certain team, the staff had provided the service user with a chair in team colours. Documentation was evident of conversations and reviewed risk assessments for service users who went into the local community without staff being present. It was evident that the service users were supported to live as independently as possible. Lifestyles Care Centre For Adults With Disabilities DS0000027965.V299210.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12 13 15 16 17 Quality in this outcome area was good. Service users were provided with a good activities programme, the activities which were appropriate for their needs. Service users had a good choice of wholesome diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has employed an activities co-ordinator for 10-20 hours per week, this person also worked as a carer within the home, and understands all the service users needs very well. There was a good programme of activities available within the home and service users were seen to be enjoying activities on a one to one basis with staff. Service users followed their own interests and activities. Some liked to socialize whilst others preferred to spend time relaxing and listening to the Lifestyles Care Centre For Adults With Disabilities DS0000027965.V299210.R01.S.doc Version 5.2 Page 12 radio or TV within their own bedrooms. Activities within the home, including arts and crafts, music and talking books, sensory stimulation within the activities room, Nail and hand treatments, and a weekly tea dance. A mini bus was provided to take service users to the theatre in Bradford, the White Rose Shopping centre Leeds, Drax Day Centre and Power Station Club for entertainment and Pontefract Town Hall. A visitor was spoken with and confirmed that an invitation to attend outings and special events organised within the home was received. Quality time could be spent with their relative during open visiting times at the home. Links with the local community were encouraged. Some service users were able to go out independently to local events, pubs and shops. The case tracked service users were not able to gain employment or work as a volunteer, but the manager stated that service users were assisted in this process if they wished and were able to work. The home manager stated that service users who required time and privacy with relatives would be ensured this. Service users would be assisted to acquire a postal vote, if required. Mail was given to service users unopened, or read to service users by staff. Lunch was observed; a good choice of food was available. Service users could choose where to eat. Menus offered lots of choice. The chef knew the needs of service users requiring a special diet. All food served looked appetizing. Service users were assisted to eat by staff on an individual basis. Some service users required peg feeds. The kitchen was examined it was clean and tidy. All fridge, freezer and cooked meat temperatures were recorded. Flooring within the vegetable preparation area had been covered over with silver tape, this flooring must be replaced. The coloured chopping boards were heavily scored and required replacing to maintain the health and safety of service users and staff. Lifestyles Care Centre For Adults With Disabilities DS0000027965.V299210.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18 19 20 Quality in this outcome area was good. Service users were well supported their physical needs were met, in a safe way. This judgment has been made using available evidence including a visit to this service. EVIDENCE: Service users were seen to be well presented and cared for with their special needs addressed. A service user stated, “The care I receive is generally fine.” A visitor stated “Staff cope admirably, I’m generally very happy with staff, and happy with the care that my relative is receiving, staff ensure that my relative is well dressed, skin, nail and hair care is all looked after well”. Service users needs were well known to staff and this enables them to instinctively know the service users needs including those that could not communicate verbally, contact and communication occurred through body language and eye movement for some service users, this was understood by staff. One case tracked service user maintained their own hygiene and was supported at the service users request. Lifestyles Care Centre For Adults With Disabilities DS0000027965.V299210.R01.S.doc Version 5.2 Page 14 Medications were administered to all service users by the staff. The home manager stated that all the service users were given their medications by staff as they had been assessed and were not able to carry out self-medication successfully. All new service users must be asked if they would like to be assessed to see if they are safe and capable of self-medicating. Medicines were stored and administered safely, however treatment sheets observed contained pharmacy labels and hand written entries, this must be avoided to prevent any transcription errors occurring, which could place service users at risk. This was discussed with the manager, who was aware of current guidance relating to this matter. The manager stated she would ensure this was rectified. The home was in the process of changing pharmacy supplier, to ensure a better service was obtained. The manager was aware of the correct method to dispose of returned medications, to protect service users and staff. However a copy of the waste disposal contract with the pharmacy was not available for inspection. The manager stated that this would be provided by fax to The Commission of Social Care Inspection. Lifestyles Care Centre For Adults With Disabilities DS0000027965.V299210.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 22 23 Quality in this outcome area was poor. Service users could be assured their concerns would be listened to, however there were shortfalls relating to recording of the investigation and the outcome for the complainant, and the finances of some service users could not be accounted for. This judgment has been made using available evidence including a visit to this service. EVIDENCE: There had been two complaints received at the home since the last inspection. One written complaint was outlined, however the recording of the investigation process could not be reviewed as it had been misplaced. The second verbal complaint related to the cleanliness of a service users carpet and inadequate gardening. The documentation relating to the action taken and outcome discussed with the service user and their family was not available, to be inspected. In view of these shortfalls .It was suggested that a complaints file should be set up to allow all documentation to be easily found, and available to be reviewed upon each site visit by the Inspector. Staff receive internal and external training relating to the Protection of Vulnerable Adults. A whistle blowing policy was in place. The manager described correctly the action that would to be taken if an allegation of this nature was received. Newly appointed staff had a Protection of Vulnerable Adults and a Criminal Records Beuro check undertaken prior to employment commencing. This Lifestyles Care Centre For Adults With Disabilities DS0000027965.V299210.R01.S.doc Version 5.2 Page 16 helped to protect the vulnerable service users. Two written references were requested, some staff had one work reference and a character reference from a friend. Staff who had been in post for many years only had one reference available. References must be sought to ensure that the information received is a true reflection of the individual’s capabilities. This was discussed with the home manager. Three personal allowance balances held at the home were checked and found to be correct. This included one service user who had a cash allowance, the service user signed for the cash. It was not possible to make a judgment relating to the financial protection of service users who received mobility allowance. These service users could not be identified because the payments go direct to Lifestyles head office. There was no record of these transactions held at the care home. There have been significant issues relating to these issues in the past. Records must be available within the care home to allow inspection of each service users personal allowance and mobility allowance transactions to ensure that vulnerable service users are being protected by the homes systems. A mini bus was provided and was available for all service users to use for hospital appointments and outings. Lifestyles Care Centre For Adults With Disabilities DS0000027965.V299210.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 27 30 Quality in this outcome area was poor. Service users live in a home that was clean but poorly maintained and decorated and in some areas unsafe. This judgment has been made using available evidence including a visit to this service. EVIDENCE: The dining area, lounge living room and activities room were spacious, airy and well decorated. A lava lamp in the activities room reflected different colours onto the hand painted cut outs on the wall, this made the room colourful and bright. The edges of some corridor carpet were held down by tape, this was apparent under some doors, this must be rectified to prevent a possible trip hazards occurring. Flooring within the kitchen vegetable preparation area covered by tape must be replaced to ensure the floor can be cleaned to maintain health and safety. One external door leading to the internal patio area had been replaced, this required painting and a lock to be fitted to ensure adequate security for service users and staff. Two hot water pipes were covered by black Lifestyles Care Centre For Adults With Disabilities DS0000027965.V299210.R01.S.doc Version 5.2 Page 18 and yellow sticky tape, these required boxing in to prevent service users or staff being placed at risk from contact burns. On the ground floor one room had to be accessed as a fire route; a notice stated “maintenance work in progress” upon inspection this room was being used for storage of equipment, however there was adequate floor space for staff and wheelchairs to gain exit. The floor covering had been removed, to expose the concrete floor, an ant’s nest was apparent, which must be attended to. The floor must be made level and new floor covering applied, to prevent this being a trip hazard. This was discussed with the manager. In the laundry an area of exposed breezeblock behind the dryer was apparent this must be tiled to ensure this area could be thorough cleaning. The dryer filter was ripped and could allow fluff to pass through it; this must be replaced to prevent this from becoming a fire hazard. The lift maintenance record indicated that it was in need of further maintenance work to be carried out. This must be completed to ensure that health and safety for staff was maintained when using the lift. The lift was not used for personnel, just to transport the medication trolley from the first floor. Occupied bedrooms inspected appeared to be suitably decorated, However 3 unoccupied bedrooms were inspected, one had weeds growing under the patio door, and the other two required redecorating. One bathroom and two shower rooms on the ground floor were inaccessible due to ongoing plumbing work to improve the water pressure and hot water temperature control. This work must be completed. One shower room water pressure was checked and found to be adequate. The hot water temperatures tested in this bathroom was within acceptable limits. Hot water temperatures within all the areas of the home were taken and recorded by the home manager, the plumbers were due to return to the home to correct temperatures recorded as being too high, This work must be completed to prevent the possibility of scalding occurring to staff or service users. The inner skin of one bathroom door had two holes present, this must be replaced. An area of plaster had fallen away from the loft hatch. There was a metal drainage cover evident in the middle of the carpet in the smokers lounge. This was discussed with the manager who stated the cover had been in place for 20 years, and it was an internal drainage cover, which must be able to be accessed. The oxford hoist required repainting again as the paint had flaked off. These issues presented the home as poorly maintained, and must be addressed. Lifestyles Care Centre For Adults With Disabilities DS0000027965.V299210.R01.S.doc Version 5.2 Page 19 Conditions in place to restrict the use of the first floor remain; this area must not be used for service users. Seven bedrooms and a lounge area on the first floor were inspected and found to be in varying sates of disrepair; the lounge required redecorating and the outer door had a 2-inch gap at floor level. Some carpets required replacing. Some bedrooms doors were padlocked shut and could not be inspected. The treatment room used for medication storage on the first floor was suitable, and well maintained. The external paintwork required redecorating; the garden and all patio areas were covered by tall grass and weeds. The wall in the car park was falling down in places, this must be repaired as some service users self propel their wheelchairs within this area, and it posed a health and safety risk to them as well as pedestrians and visitors to the home. These issues highlight the unacceptably poor presentation of the care home and must be addressed. The poor standard of maintained décor within some areas of the home detracted from the good care given to service users. The manager and staff stated that “ the environment was letting us down, admissions were put off due to the poor environment. A visitor stated “ although a lot of work had been undertaken, the home does not look inviting in some areas to visitors, It would be nice to have some garden furniture and a parasol, to be able to use the patio areas which needed tidying up.” Staff stated they were embarrassed to show people round, they felt that the environment detracted from the good care being provided. Lifestyles Care Centre For Adults With Disabilities DS0000027965.V299210.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 34 32 35 Quality in this outcome area was good. Service users were looked after by adequately trained staff, however not all the staff had two written references on file. This judgment has been made using available evidence including a visit to this service. EVIDENCE: Staff files were inspected; staff supervision was undertaken and recorded, this ensures that the quality of the service delivered to service users was regularly monitored. Staff files for each member of staff were evident, they included certificates for training undertaken, and this helped to ensure service users were cared for by well-trained staff. Some staff files inspected only had one written reference, some second references were from friends, and were character references only. This was discussed with the manager. Two written work references should be gained for each member of staff wherever possible, and if this is not possible character references should be gained from professional referees. The shortfalls should be addressed. Lifestyles Care Centre For Adults With Disabilities DS0000027965.V299210.R01.S.doc Version 5.2 Page 21 All new members of staff had completed a POVA First check and a Criminal Records Beuro check prior to commencing work at the home. One member of staff had not received the CRB back before their start date, supervision had taken place until the result came through, and this protected the service users and staff. Staff received internal and external training in relation to the protection of vulnerable adults. Training was also given in moving and handling and food hygiene. Induction training was being given to all new staff. Care staff were encouraged to undertake the National Vocational Qualification in Care. The home manager had commenced the National Vocational Qualification in Management level 4. This ensures service users received care from welltrained staff. Staffing within the home was stable; all staff spoken to was committed to the service users within the home. Staff who worked 48 hours or more all had a signed working time directive disclosure within their staff file. Staff must be monitored by management to ensure that they are not becoming over tierd, when working these hours. The manager must take action if there are concerns relating to this. A self-employed handy man attended the home a few hours a week although he had not been at the home for the last two weeks. This was an improvement, as it allowed some maintenance issues to be addressed. Lifestyles Care Centre For Adults With Disabilities DS0000027965.V299210.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37 39 42 Quality in this outcome area was adequate. Service users benefit from the management style of the home manager, however there were issues relating to environmental health and safety detrimental to service users, which need to be addressed, by the provider. This judgment has been made using available evidence including a visit to this service. EVIDENCE: The manager was dedicated to the home, and had implemented systems within the home to ensure staff and service users were monitored, to ensure the home was running smoothly on a day-to-day basis a visitor commented, “ Since this manager started, there is more to do, they try to do something different everyday with the service users”. Lifestyles Care Centre For Adults With Disabilities DS0000027965.V299210.R01.S.doc Version 5.2 Page 23 Staff and a visitor stated that they valued the new manager and her approach, as well as the new systems, which she had implemented within the home .It appeared that the proprietor who had not addressed several outstanding, ongoing environmental issues, relating to the homes environment and excessively hot water temperatures, poorly supported her. Surveys were sent out yearly, to relatives, as most service users could not complete these. The results were then collated and a report produced which was shared with residents, relatives and visitors. The menu had just been changed following a survey of service users, the new menu offered more choice. Service users would be asked for their feedback later in the year. This process was completed six months ago. The manager gained verbal feedback from social workers and the general practitioner. Staff meeting were held for nurses, carers and night staff. An annual development plan was currently being developed for the home. Quality monitoring was undertaken internally and externally by an annual survey conducted by the MS society. This survey stated that in November 2005 “The team found the centre to be in need of a real facelift, including the replacement of some carpets and some decoration. This detracts from the good work being done by the manager and her team.” A further assessment was due later in 2006. Since the MS society survey, certain carpets had been replaced and some decoration carried out. Moving and handling training occurs. Fire equipment and fire checks were made weekly. The home had acquired the services of a self-employed handyman a few hours a week, but he had not attended the home in the last two weeks. The home manager takes and records the hot water temperatures. Also in the absence of the proprietor the manager recorded the weekly fire alarm test and checked the emergency fire lighting. Training was being delivered to staff; a training matrix will be developed and implemented to ensure staff training remains up to date. Lifestyles Care Centre For Adults With Disabilities DS0000027965.V299210.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 2 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 1 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 1 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000027965.V299210.R01.S.doc 2 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 1 X Version 5.2 Page 25 Lifestyles Care Centre For Adults With Disabilities Yes 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 YA6 Regulation 15 (2) (6) Requirement Service users plans must be reviewed at least 6 monthly or as service users needs change. It may be beneficial to review these monthly. A copy of the medication waste disposal contract must be supplied to the Commission for Social Care Inspection. All service users records relating to personal allowance accounts and mobility allowance must be held at the care home for inspection. The two hot water pipes within the corridor covered in black and yellow tape must be boxed in to protect service users and staff. All areas of carpet where tape has been applied must be reviewed. Appropriate methods must be adopted to ensure the carpet is adhered to the floor. The area of flooring in the vegetable preparation area covered with tape must be replaced. DS0000027965.V299210.R01.S.doc Timescale for action 14/07/06 2. YA20 13 (2) 14/07/06 3. YA23 17 & sched 4 9 13 (4) (a) 14/07/06 4. YA24 30/07/06 5. YA24 13 (4) (a) (c) 25/07/06 Lifestyles Care Centre For Adults With Disabilities Version 5.2 Page 26 6. 7. 8. 9. 10. YA24 23 (2)(o) 23 (2) (b) 23 (2) (b) 16 (2) (g) 23 (2) (c) YA24 All patio areas and garden must be kept free from weeds and tall grass, and all times. The outside doors and windows must be repainted. The stonewall in the car park must be repaired and this must be maintained. The coloured chopping boards within the kitchen must be replaced. The lift maintenance record highlighted outstanding work was required. This work must be undertaken. The water pressure in all resident bathrooms must be sufficient to ensure that residents can have a bath (previous timescale of 30/09/05 and 14/01/06 not Met) Hot water temperatures to each service users bedroom must be supplied on or around 43 degrees centigrade. Remedial action must be taken for all bedrooms having water temperatures exceeding this. The area of exposed breezeblock behind the tumble dryer must be tiled, to enable adequate cleaning to take place. The provider must inform the Commission for Social Care Inspection in writing prior to using the rooms upstairs. This is due to the environmental requirements that were previously made. A further assessment of these rooms would then be made to see if the environment would be suitable for use. DS0000027965.V299210.R01.S.doc 14/07/07 18/08/06 30/07/06 30/07/06 18/09/06 YA24 YA24 YA24 11. YA27 23 20/07/06 12. YA27 23 & 13 (4) (a) 20/07/06 13. YA30 13 (4) (c) 30/07/06 14. YA42 13 06/06/06 Lifestyles Care Centre For Adults With Disabilities Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard YA22 YA23 YA24 YA29 YA39 Good Practice Recommendations The home should ensure all documentation relating to complaints received are held within a folder, and are available for inspection. The home should gain two professional work references for all employees, which should be held on file for inspection. Consideration should be given to increasing the hours worked by the self-employed maintenance person. The Oxford hoist has corroded and should be painted. The home should continue to develop an annual development plan. Lifestyles Care Centre For Adults With Disabilities DS0000027965.V299210.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Lifestyles Care Centre For Adults With Disabilities DS0000027965.V299210.R01.S.doc Version 5.2 Page 29 - 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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