Inspection on 17/04/07 for Lincolnshire House

This inspection was carried out on 17th April 2007.

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

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

Other inspections for this house

Lincolnshire House 12/01/06

Lincolnshire House 20/09/05

Lincolnshire House 14/02/05

Lincolnshire House 24/08/04

Lincolnshire House 30/03/04

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

CARE HOME ADULTS 18-65 Lincolnshire House Brumby Wood Lane Scunthorpe North Lincolnshire DN17 1AF Lead Inspector Stephen Robertshaw Unannounced Inspection 17th April 2007 09:30 Lincolnshire House DS0000002909.V335461.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 Lincolnshire House DS0000002909.V335461.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. Lincolnshire House DS0000002909.V335461.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lincolnshire House Address Brumby Wood Lane Scunthorpe North Lincolnshire DN17 1AF 01724 844168 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) admin@lincshouse.com Lincolnshire House Association Belinda Samantha Jane Parrington Care Home 33 Category(ies) of Physical disability (33) registration, with number of places Lincolnshire House DS0000002909.V335461.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home can only accept the specified service user HC with mental health needs. 12th January 2006 Date of last inspection Brief Description of the Service: Lincolnshire House provides accommodation for 33 adults with a physical disability in several individual purpose built bungalows. The most recent being opened in March 2002. All the bungalows are furnished to a high standard and are self contained incorporating appropriately adapted kitchens, dining rooms, lounges, laundry and bathrooms. All bedrooms are for single occupation with 24 of these having en suite facilities. The remaining 7 bedrooms have a wash hand basin in the room. Particular attention has been given to provide adaptations such as overhead tracking, portable hoists, automatic bathroom lighting, automatic key coded entrance doors and extra wide door access all promoting individuals independence. A new building has been erected in the grounds to replace the old education block. The building is used for educational classes and social events. The grounds are well maintained and fully accessible to wheelchair users. CCTV has been installed to monitor the entrances of the premises for security purposes. The home is close to local amenities and the town centre of Scunthorpe. The current fees for services at the home are between £399 and £814 per week. The statement of purpose for the home details what services the weekly fees cover. A copy of the homes previous inspection was on open display for the service users and visitors to the home to access. Lincolnshire House DS0000002909.V335461.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of Lincolnshire House was unannounced and took place on the 17th of March 2007. The term resident is used throughout this report, as this is the way in which the people who live at Lincolnshire House prefer to be addressed. The evidence for the report was gathered through the inspections observation during the site visit and information gathered through surveys that had been returned to the inspector before the visit took place and case tracking of residents living at the home. This included looking at residents care files and observing the staff employment and training records and observations of the quality assurance records for the home. Management and care staff were interviewed by the inspector who also had discussions with nine of the residents living at the service. The Commission sent out thirty-one residents surveys and twenty-two were returned to the Commission before the site visit-taking place. Forty-six surveys were sent out to staff working at the home however only five were returned before the inspector visited the service. The inspector also contacted the social workers for three of the residents living at the home to gain their views on how the service meets the needs of the residents. What the service does well: The home provides a very homely and friendly environment for the residents to live in. The staff and the residents appear to have very good relationships with each other and the atmosphere between them is relaxed. This means that the residents are very settled and feel that they can rely of the staff for any support that they may need. The residents are very involved in the management of the service and have an interest in how the service develops. Residents are provided with meals that they choose and like, however they are encouraged to follow a healthy diet including lots of fresh fruit and vegetables to try and maintain their health. The residents told the inspector that they enjoy their meals at the home and said that they bare involved in choosing their menus. Lincolnshire House DS0000002909.V335461.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Lincolnshire House DS0000002909.V335461.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 Lincolnshire House DS0000002909.V335461.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): 1,2,3,4 and 5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. This means that prospective new residents to the service are given the opportunity to visit the service and experience trail periods at the home to make sure that it is suitable to them to meet their individual needs. EVIDENCE: Since the last inspection the home has increased the numbers of places available to the residents by two. This has been included in the information made available to prospective new service users. The charity is considering developing the service further on a new local site due to the number of requests for information and availability of resources provided through the current service. This would hopefully reduce any ‘waiting lists’ for residential vacancies within the service. The inspector observed all of the case file information in relation to three of the residents that were living at he home. The files showed that they had all received a comprehensive assessment of their individual needs before they had been admitted in to the home. This included assessments completed by their funding authorities and a pre-inspection admission that had been completed Lincolnshire House DS0000002909.V335461.R01.S.doc Version 5.2 Page 9 through senior staff working in the service. The homes assessments should include the signature of the person completing the assessment so that it can be identified at a later date who completed the work. The observations during the course of the site visit, observation of training records and discussions with service users supported and confirmed that the home can meet the assessed needs of the service users. One service user stated that ‘I am given all of the help that I need, and the staff and management are very friendly’. A large amount of the residents have lived at the home a very long time and when they were admitted there was not really any choice in the matter as it was the only service available at that time that could meet their individual needs. However residents that had been admitted in more recent times said that they had been able to experience trail periods at the home before deciding to move there on a more permanent basis. This had included day visits and overnight stays. Several service users stated to the inspector that they had originally attended the services day care facilities and then when their carers in the community could no longer meet their individual needs they decided to move in to the home as they already knew the other residents and the staff through their previous contact with them. All of the care files observed by the inspector included a contract with their local authority for their placement at the home and there were individual contracts between the residents and the management of the home detailing the services that would be provided to them through their funding. Lincolnshire House DS0000002909.V335461.R01.S.doc Version 5.2 Page 10 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): 6,7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that residents are actively involved in the development of their care plans and are enabled to take risks as part of supporting an independent lifestyle. EVIDENCE: The inspector observed the care files for three of the residents living at the home. All of the files included care plans that supported all of the individual needs of the service users. Some of the information in the care plans could be developed further to include greater detail of how individual residents needs must be supported or met through anyone offering care to them. The homes care plans reflected all of the needs identified in the residents care management care plans that were also included in their files. All of the service users are allocated a key worker and all of the residents spoken to by the inspector were aware of the responsibilities of a key worker. The residents care Lincolnshire House DS0000002909.V335461.R01.S.doc Version 5.2 Page 11 files also included key worker contact sheets. The manager was aware that these records needed further development to identify what should be recorded on them and informed the inspector that training had been planned for the staff in relation to how key workers should perform their duties and how they should record them. The residents within the service are provided with various opportunities to make decisions in relation as to how services are provided to them and in relation to the future development of the service. The service users spoken to by the inspector informed him of the committees that they are involved in for the service, these included an ‘activities committee’ and a ‘business development committee. The records in the home supported the fact that the residents are supported to maintain their own finances wherever they have the ability to manage this, alternatively if residents do not have the ability to manage their own finances then the service offers them appropriate support to manage their personal finances. There was evidence to suggest that this was either provided through the home itself, resident’s families, or their representatives including solicitors. The care plans for the individual service users included risks assessments to support them where appropriate. The risks assessments ensured that the residents are supported to take risks as part of an independent lifestyle and that residents that display behaviours that pose a risk to either themselves or other people have behaviour management guidelines to evidence that they or their representatives have signed and agreed to any limitations on facilities, choice or human rights. All of the information recorded in relation to the residents at the home are stored in accordance with the Data Protection Act 1998 and other relevant legislation and good practice guidelines. Lincolnshire House DS0000002909.V335461.R01.S.doc Version 5.2 Page 12 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 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. This means that the residents are supported to develop and maintain their individual lifestyles while living at the home. EVIDENCE: The residents living at the service are provided with very good opportunities to develop and maintain their social, emotional, communication and independent living skills. Some of the residents are engaged in unpaid work placements; one helps out at Scunthorpe United AFC, one at the Scunthorpe Bus station and the other helps the gardener/handyman at the home. The remainder of the residents take part in a wide range of activities to continue their opportunities for personal development. This included Lincolnshire House DS0000002909.V335461.R01.S.doc Version 5.2 Page 13 educational and leisure activities. The service employs activity staff to develop opportunities for the residents to become involved in, either in groups or as individuals. Residents are encouraged and supported in to taking an active role in household chores in their bungalows and they all have at least one day at home to change their beds, clean their rooms and do their laundry. Where support is identified as being required in the residents care plans for any of these needs then appropriate staff support is provided. The education centre provides a fully accessible modern bright facility. Some residents attend and take part in activities such as keep fit, IT, art, communication skills and baking. There is also a ‘railway group’ that has recently been developed on an evening at the centre. Residents also attend local venues to receive adult education classes to provide numeric, literacy and information technology training. Residents enjoy an active social life which is detailed in their individual care files this includes going to the cinema, theatre, bowling, swimming, shopping, visits to the hairdresser, walks and out for meals at the pub. One resident told the inspector that she enjoys ‘going to the pub for a lager’ and admitted that some times they overdid it and ‘felt sick the next day’. The resident and the care staff saw this as a learning experience. The residents all either visit their parents/relatives at home or are visited by them at Lincolnshire House and contact is welcomed and supported. The care staff help to promote a healthy eating menu for the individual residents whilst at the same time trying to balance this with resident’s likes/dislikes and special treats on occasions. The home have a catering manager who regularly goes around the home and speaks to the residents prior to undertaking the ordering for the homes provisions, the inspector was informed that on the whole anything residents ask for is catered for. Any restrictions are clearly documented in the care file and agreed to by the resident however this was identified as usually being due to medical reasons. Lincolnshire House DS0000002909.V335461.R01.S.doc Version 5.2 Page 14 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): 18,19,20n and 21 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. This means that the residents are provided with all of the support that they require to meet their personal and healthcare needs. EVIDENCE: The home does not provide nursing care to the residents. However the care files observed by the inspector provided evidence that their healthcare needs are met through appropriate professionals that are based in the community. This included contact with GP’s, district nurses, dentists, chiropodists and opticians. Residents confirmed to the inspector that they attended these appointments by themselves when they could, or otherwise staff from the home would support them with the appointments if the resident requested them to. The philosophy of care in the home was observed to be very relaxed and was informal and the staff appeared to be sensitive to the residents needs and were responsive to any requests made of them. Lincolnshire House DS0000002909.V335461.R01.S.doc Version 5.2 Page 15 Care files showed that support from health professionals was obtained on behalf of the resident where required, for example speech therapist and dietician. Residents informed the inspector that they could choose their own clothing, and choice was made for their preferences for getting up and going to bed. One resident told the inspector that they ‘found it hard to get up in a morning’ so the staff ‘always ‘ prompt and encourage the to get up by a ‘reasonable time’. The inspector saw that technical aids were provided to ensure that residents had maximum independence such as electric wheelchairs, automatic door opening and closing, and movement sensitive lights and where appropriate mechanical hoists in their own rooms. Some of the staff have received training in the administration of medication. The manger of the service stated to the inspector that it has become difficult to identify accredited medication training recently and therefore was introducing BVS training for the staff that require safe handling of medication training. The medication record sheet for one of the service users had an omission on the previous days records. There were no other errors identified. The member of staff on duty was aware that of the omission and had contacted the member of staff responsible to identify if the medication had been administered. Several of the residents self administer their own medication, however the staff re-order any medication that is required for them. The service needs to introduce risk assessments to cover the residents that are self administering their own medication. All of the care files seen by the inspector had the residents last wishes in the event of their deaths identified. Lincolnshire House DS0000002909.V335461.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. This means that the service users are protected from possible abusive situations at the home. EVIDENCE: There had been no formal complaints made at the home since the last inspection. The residents spoken to by the inspector all knew how to make a complaint in relation to the home if they wished to. The residents also told the inspector that their view are often sought and listened to and therefore the services they received were the services that they wanted, being delivered in a way that they preferred. Several residents also said to the inspector that they are involved in Committees at the home and if any resident has any concerns then these can usually be met through one of the Committees taking appropriate actions. Staff training records showed that all of the care staff receive protection of vulnerable adult training to make sure that they can safeguard the residents from abuse. Staff spoken to by the inspector were all aware of safeguarding issues and understood how to report any suspicions or allegations of abuse. Lincolnshire House DS0000002909.V335461.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): 24,25,26,27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment is suitable to the needs of the individual service users are their individual rooms are tailored to their individual needs. EVIDENCE: Lincolnshire House DS0000002909.V335461.R01.S.doc Version 5.2 Page 18 The home was located close to all of the local amenities including shops, college and leisure facilities. It is also close to the town centre of Scunthorpe. The home is in keeping with the surrounding area as the street had many different styles of residential properties. The home is divided into separate bungalows that provide a more homely atmosphere for the residents. The bungalows provided very good quality domestic style furniture and there is ample space for wheelchair users to move around the home and grounds freely and safely. The premises were accessible to all of the residents with corridors and doorways being widened to provide easy access for wheelchairs. At the time of the site visit two of the bungalows were in the process of having new kitchen units and appliances fitted. Domestic staff are employed at the home, they are responsible for the general cleanliness of the home, however the residents themselves could choose to keep their own bungalows clean with any support that they require. The inspector’s tour of the premises identified that it was very clean and tidy and was free of any offensive odours. The Laundry facilities provided in each of the bungalows were domestic in character and were programmable to disinfection and sluicing standards. Residents are given support to use the washing machines by themselves, however if they need support to do their washing this is identified in their individual care plans and the care staff provides appropriate support to them A sluice was provided in one of the bungalows. There were no infection control concerns identified in the home. One service user had returned to the home from hospital MRSA positive and all appropriate and correct procedures were maintained to ensure the health and safety of the individual service user, their peers and the staff group. The inspector was invited to look at the bedrooms of seven of the residents. These had all been decorated and furnished to their own tastes and preferences. This included items of furniture including beds and wardrobes and personal pictures, ornaments and soft toys. Twenty-six of the thirty-one bedrooms include en-suite facilities. A further ten toilets and eight bathrooms are provided at the home. One service user said ‘It is lovely here, it is my home, I have lived here for a long time and I am settled’. Lincolnshire House DS0000002909.V335461.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): 31,32,33,34,36 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the staff have the necessary knowledge and skills to meet the needs of the residents. EVIDENCE: The majority of the staff working at Lincolnshire House have been working there for a considerable length of time. However due to the development of the service and staff leaving the service for personal or retirement issues this has meant that new staff have been employed to work with the residents since the last inspection. The inspector observed the personnel and training records for three of the staff employed to work at the home. Two of these were for new staff and one was for an established worker with the service. These files supported the evidence that all of the staff receive all of the appropriate security vetting before they have any access to any of the residents or their records to safeguard them from harm. All of the records supported that equal opportunities are embraced in the employment of new staff to the service. Lincolnshire House DS0000002909.V335461.R01.S.doc Version 5.2 Page 20 It was clear from inspector’s direct observation and discussions with staff that they knew how to meet the needs of residents and there was good evidence in care files of the involvement of other agencies with specific expertise. One service users stated to the inspector ‘the staff are very friendly and helpful’. Training records observed by the inspector supported the evidence that staff receive all of the mandatory training required of them this includes fire safety; moving and handling; food hygiene, first aid, health and safety and infection control. The manager of the home keeps a clear audit when any of the staff require refresher training in any of these areas. There was also evidence to suggest that the care staff receive training that is specific to the needs of the resident group and this included training in relation to epilepsy, diabetes, peg feeding, use of hoists and slings and foot care, knowledge of disabilities and specific conditions of residents and dealing with difficult behaviours/conflict. Staff and management commitment towards NVQ training is very positive and approximately 50 of the care staff have completed NVQ 2 or above in care. The staff records also supported that when they begin to work t the home they receive appropriate induction training that meets the required standards for induction. The inspector’s observations during the course of the site visit confirmed that the staff respect the residents and were approachable and they were motivated and positive towards their duties. Regular formal recorded staff supervision and annual appraisal provides the staff with the opportunity to identify any training needs and to make sure that they understood the needs of the residents that they were working with and staff receive at least five paid training days (pro-rata) a year. The supervision process in the home is very good. New workers to the home are provided with formal supervision at least once a month for the first six months of their employment to offer them additional support. Supervision records showed that when the staff members were more comfortable in their work then the supervision was extended to once every two months in line with the minimum requirements for supervision. The home does not employ any staff under the age of 18. There is one volunteer involved with the service users at the home. They are involved in helping out with the homes activities. The voluntary worker has received an up to date Criminal Record Bureau clearance. Lincolnshire House DS0000002909.V335461.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): 37,38,39,41,42 and 43 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. This means that the management of the home supports the need of both the residents and the staff group. The home is well run and managed from the board of trustees to the staff team, with a wide range of policies and procedures that are regularly reviewed and monitored which promote residents rights and best interests. The residents are very much involved in the management of the service. EVIDENCE: The manager of the home has a great deal of experience of working in the care field and has a good working knowledge of the needs of the service users. She has completed the Registered Managers Award and the NVQ 4 in care. Lincolnshire House DS0000002909.V335461.R01.S.doc Version 5.2 Page 22 The management ethos is open and approachable. The residents all refer to the management and manager of the home by their first names and stated that they have very good access to the manager and senior managers of the service. The residents are very much involved in the management processes of the service including their individual involvements in the services different committees. These committees dictate how the services will develop in the future. Regular house meetings include staff and residents meetings, staff supervision and the key worker system all make sure that staff and residents have the opportunity to influence the way in which the services are delivered. The homes quality assurance and monitoring system has improved since previous inspections and requirements. Regular questionnaires are sent out to different people to gain their views on the services that are provided through Lincolnshire House. This included care management, healthcare services, visitors and the residents themselves. The manager of the home analyses all of the returned questionnaires and this formulates an action plan for the future delivery of services. The results of the surveys are made public within the service itself, the inspector discussed with the manager how this information could be extended to reach a wider audience. To support the homes quality assurance programme it has been assessed and was accepted for the QDS gold award through the local authority. All of the approrpate reocrds that are required by regulation were in position and were stored in accordance with the Data Protection act 1998. Linconlnshire House has a Health and Safety Policy, appropriate notices were displayed in the home and all staff had received mandatory training. All maintenance checks are routinely carried out and the responible individual carries out monthly regulation 26 visits. A copy of this repoort is routinely sent to the Commission. All of the necessary insurnace policies were in place and this also included the insurance for the homes motor vehicles. Lincolnshire House DS0000002909.V335461.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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 4 25 3 26 3 27 3 28 3 29 3 30 4 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 2 3 3 4 3 X 3 3 3 Lincolnshire House DS0000002909.V335461.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 13.2 Requirement The registered person must make sure that all records of administered medication are up to date and have been accurately recorded. Timescale for action 19/04/07 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. Refer to Standard YA6 Good Practice Recommendations The registered manager of the home should make sure that there is a consistency in the quality and content of the information recorded in the individual service users daily diary and key worker records. 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