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Inspection on 11/02/09 for Lingdale Road (7)

Also see our care home review for Lingdale Road (7) for more information

This inspection was carried out on 11th February 2009.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

Inspecting for better lives Key inspection report Name: Address: Lingdale Road (7) 7 Lingdale Road West Kirby Wirral CH48 5DG 1 Star Adequate The quality rating for this care home is: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Helen Carton Date: 1 1 0 2 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area Outcome area (for example: Choice of home) These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement Copies of the National Minimum Standards – can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Internet address www.csci.org.uk Information about the care home Name of care home: Address: Lingdale Road (7) 7 Lingdale Road West Kirby Wirral CH48 5DG 01516324845 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Royal Mencap Society Name of registered manager (if applicable) Deborah Anne Pierce Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 Over 65 7 0 care home 7 learning disability Additional conditions: The registered person may provide the following category of service only: Care home only - Code PC. To service users of the following gender: Either. Whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD. The maximum number of service users who can be accommodated is: 7. Date of last inspection 1 8 1 0 2 0 0 6 A bit about the care home Lingdale Road is registered to provide personal care for 7 adults with a learning disability. The home is a three storey, detached house located in a residential area of West Kirby. Lingdale Road is close to local shops and to public transport services. All bedrooms are single. There is a shower room on the ground floor and a bathroom on the first floor. On the ground floor there is a kitchen, two lounges and a separate dining room. There is a large garden to the rear of the home. There is a preparation for independent living flat situated on the third floor for two service users, which has cooking facilities and a shared bathroom. Parking is available at the front of the home and on the road outside. A copy of the most recent Commission for Social Care Inspection (CSCI) report is available from the manager of 7 Lingdale Road. Currently service users pay 444 pounds per week to live at the home. Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: 1* Adequate Choice of Home Individual needs and Choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home How we did our inspection: This is what the inspector did when they were at the care home As part of the inspection process we visited the home to enable us to look at the records and to discuss how the home support service users in all aspects of their lives. As part of this process we spoke with a manager, members of the staff team and spent time with service users to find out their views on living at 7 Lingdale Road. Following our visit we sent surveys to four service users and five members of the staff team, none were returned. The last inspection on this service took place on 18/10/2006 We spent approximately 7 hours at the home What the care home does well The manager and the staff team work hard to support service users to be active and to be involved in activities in the community and to meet up with their friends and families. There have been very few changes in the staff team in the last twelve months, which means service users can get to know the people who are supporting them very well. The manager and the staff team support service users to go on holiday each year, which they enjoy very much. Services users spoken with made the following comments: I go to the -------- Mondays, Wednesdays, Thursdays and Fridays I go on the bus by myself I really enjoy it. I like going to the cafes in West Kirby and looking round the shops I go out at night to my clubs I am going tonight and will see my friends I like that Im going on holiday with A, B and C were going to have a lovely time I like going on holiday. Each service user has a care plan which shows the type and level of support they need this information helps the staff team to get to know service users and to understand what is important to them. The manager and the staff team listen to service users if they are concerned about anything and try and sort things out for them before it causes too much distress or upset. Service users spoken with made the following comments: I would talk to my family and Debbie if I was not happy about something in the house. If I was sad I would talk to Debbie the manager or P a member of staff, they would make me feel better. Mencap who run the home support the staff team to go on training courses to help them understand the best ways to support and care for service users. What has got better from the last inspection Since our last visit to the home more of the staff team have gained National Vocational Qualifications in care. These qualifications give staff members confidence in their work, which means service users are being supported by a more skilled workforce. What the care home could do better The home needs to give clearer information about the services they provide and those they do not. As the lack of meaningful information makes it difficult for people who may want to live there make an informed choice as to whether 7 Lingdale Road is the best place for them. Mencap have not given service users contracts of terms and conditions or supported them to receive tenancy agreements from the housing association that owns 7 Lingdale Road. This leaves service users vulnerable and means their legal rights, as customers of Mencap services and tenants of the housing association are not being protected. The building needs maintenance work carried out on it to make it a safer and more attractive place for service users to live in. On a small number of occasions decisions have been made which may not have been in the best interest of service users. Resulting in their lifestyle choices and decision making not always being acknowledged or supported. The manager told us she would review how decisions are made to ensure service users rights are protected. Some records the manager and the staff team have to keep were not very clear and sometimes important information was not recorded, which meant the right action could not be taken. At these times service users health and safety was put at risk. If you want to read the full report of our inspection please ask the person in charge of the care home If you want to speak to the inspector please contact Helen Carton Commission for Social Care Inspection Unit 1 Tustin Court Port Way Preston PR2 2BR 01772730100 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line - 0870 240 7535 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Information provided by Mencap about the services, facilities and the legal responsibilities of living at 7 Lingdale Road are poor. Resulting in service users rights as citizens not being promoted or protected. Evidence: The statement of purpose and service user guide do not give clear relevant information about the home. Service users have not been provided with written statement of terms and conditions or a contract to inform them of what is included in the fee, any liabilities and the care and support to be provided. This results in Mencap who run 7 Lingdale Road not being open and transparent in their dealings with service users already living at the home and those people who may be considering moving in. 7 Lingdale Road is owned by a housing association meaning service users are tenants they currently have no tenancy agreements and it is unclear what role Mencap has to supports them to raise concerns about the maintenance of the building. Resulting in service users rights as citizens not being promoted or safeguarded. Before a person moves in to the home information is gained from them, their families and other professionals who may have been involved in supporting them. Following this assessment a decision is made as to whether the person is invited to move in, records show this process happens. However the assessment does not consider the poor condition of some of the facilities provided and how this may affect the person wishing to move in. This may result in service users preferred lifestyle choices and their ability to remain independent being restricted. Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Service users basic care needs are being met. However on occasions service users lifestyle choices and rights to make decisions about financial matters are not being acknowledged or supported. This results in the holistic needs of service users not being fully met. Evidence: Each service user living at 7 Lingdale Road has a care plan, which provide information about the care, and support they need. A document called About Me gives information about service users lifestyle choices and preferred routines. It focuses on the achievements of service users and supports the staff team to provide appropriate care and support to enable them to maintain life skills and their independence. There is good information that shows service users are on the whole supported to make decisions about their daily lives. However on occasions service users lifestyle choices have not been acknowledged or promoted. This has resulted in some service users lifestyle choices being only partly met by the manager and the staff team. We looked at some financial records to see how service users are supported to make decisions about how they spend their money. On a small number of occasions decisions have been made which may not have been in their best interests. The manager agreed to review how some decision are made and to put a procedure in place which gives clear guidance to the staff team and safeguards service users. A selection of risk assessments were looked at they were detailed and supported service users to maintain life skills and their independence, they are currently Evidence: reviewed every six months. We discussed with the manager the need to look at this timescale and to review those, which involve service users health and safety more frequently. Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Service users views and wishes are usually valued and form the basis of social and leisure activities provided by the home. Resulting in appropriate support being offered to maintain their emotional and mental well being. Evidence: Records and discussions with service users, the manager and members of the staff team shows there is a strong commitment to supporting service users to develop and maintain skills including social and independent living skills. This supports service users to have control of their daily lives and to feel a valued part of the house community. Service users rights to maintain their religious beliefs are supported by the manager and the staff team. Service users are supported to maintain friendships and family relationships. However on occasions individuals have not been supported to access information or community groups, which may have a positive impact on their emotional wellbeing. The majority of service users attend clubs or centres during the day and are supported to be involved in meaningful activities during the evenings and weekends. The manager and the staff team support service users to arrange holidays and short breaks throughout the year. Service users spoken with told us they enjoyed their Evidence: holidays very much The following comments were made by service users spoken with during our visit to the home: I go to the -------- Mondays, Wednesdays, Thursdays and Fridays I go on the bus by myself I really enjoy it. I like going to the cafes in West Kirby and looking round the shops I go out at night to my clubs I am going tonight and will see my friends I like that Im going on holiday with A,B and C were going to have a lovely time I like going on holiday. Service users have keys to their bedroom doors to offer them privacy and the ability to spend time on their own if they choose. This promotes service users independence and rights to have control over their daily routines. We observed the manager and members of the staff team supporting service users in a respectful and friendly manner. We looked at the food stores which had a lot of pre made meals we discussed with the manager the need to ensure service users receive a balanced and nutritious diet. This is to make sure every effort is made to support service users to develop and maintain healthy lifestyles. We advised her to contact the dietician service for advice, the manager contacted us by email to let us know she had contacted the service and was awaiting a response. Support workers are responsible for most of the catering task and support service users to be involved in menu planning and food preparation. This enables service users to develop and maintain daily living skills. Service users spoken with told us they enjoyed the meals and snacks provided by the staff team. Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Service users personal care needs are met in a skilled and sensitive manner. However on occasions their health care needs are not being fully met resulting in service users being provided with an inconsistent service. Evidence: We looked at a sample of care plans that provided information about how service users wish to be supported with their personal and intimate care needs. Overall these plans provide good information to enable the staff team to support service users sensitively and appropriately. However information held in risk assessments about supporting individuals to mobilise and transfer was limited. Leaving service users at risk of being supported unsafely and the possibility of being injured. Record show service users are supported to access health care services such as dentist, opticians, GPs and podiatry. Each service user has a medical passport that details their health care needs this type of information is also held in other records. The quality and level of detail held in some of these records is limited with little guidance or instruction available to the staff team. This leads to confusion resulting in some health care needs not being monitored effectively. This leaves service users vulnerable to receiving inappropriate and unsafe care, which may result in health care conditions deteriorating. Some specific health care training is out of date the manager told us the staff team are in the process of renewing this training. 7 Lingdale Road use a monitored dosage system to administer oral medication to service users. Evidence: Risk assessments have been carried out to support those service users who wish to administer their own medication. These risk assessments need to be more detailed and reviewed more often than every six months. This is to make sure the manager and the staff team are confident that service users continue to be able to safely administer their medication. There were no medication information sheets available for the staff team to refer to if they were concerned that service users had either overdosed or were experiencing side-effects of prescribed medication. We advised the manager to seek advice from the dispensing pharmacist and to gain information sheets on all prescribed medication. Following our visit the manager e-mailed us on 12/02/09 to confirm she had contacted the pharmacist who was now supplying the information leaflets. We looked at a sample of medication administration record sheets and discussed a number of issues with the manager. Food supplements entered on the medication administration record sheets had not been signed as administered or that the service users had refused. The manager stated the service users did not like this food supplement and had refused to take it she acknowledged she had not contacted the GP to discuss this issue. This leaves service users at risk of becoming malnourished and the possibility of further deterioration of existing health care conditions. Since our visit to the home the manager has informed us in an e-mail dated 12/02/09 that the GP has been informed and the food supplement had been stopped. We noticed that a room used to store food supplements was unlocked and could be accessed by all service users we advised the manager to ensure a lock was fitted to the door. This is to protect service users rights to privacy, confidentiality and to protect service users health and well being. Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Service users views and opinions are sought and acted upon. The homes policies and procedures protect residents from abuse. Evidence: 7 Lingdale Road is run by Mencap who have a corporate complaints policy and procedure. This process is used in the service to support service users, their families and friends to raise concerns or to complain. We discussed with the manager the need to review this document to make sure it is in formats that make the information meaningful to the people living at the home. However service users spoken with told us they felt confident talking to the manager or other significant people in their lives if they were concerned about anything. Service users spoken with during our visit made the following comments: I would talk to my family and Debbie if I was not happy about something in the house. If I was sad I would talk to Debbie the manager or P a member of staff, they would make me feel better. The manager and the staff team have undertaken safeguarding training, Mencap as an organisation provide refresher training on a regular basis. There are policies and procedures in place including whistle blowing policies and information about the local adult social services safeguarding teams. Services users spoken with provided the following comments: If I was frightened I would tell Debbie or A at the centre. My family come and see me if I was unhappy I would tell them and they would talk to the staff. Evidence: If Debbie wasnt here I would talk to the staff or L the area manager. Members of the staff team spoken with demonstrated a good understanding of safeguarding vulnerable adults from abuse and neglect and their roles and responsibilities. They provided the following comments: If I saw service users being mistreated in any way I would tell Debbie if she wasnt here I would ring a duty manager. If a service user told me they had been hurt in any way I would speak to Debbie or L, service manager, you or the police. Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . The home is not maintained and does not provide a homely, comfortable and safe environment for service users to live in. Evidence: A tour of the building highlighted the following concerns: Paintwork in the dining room is chipped and damaged the door is also damaged with varnish peeling off. In the downstairs shower room the fitted shower chair is very rusty, the mobile shower chair has very little room to be manoeuvred. There is damaged plasterwork, peeling wallpaper and stained wallpaper the paintwork on the skirting boards, window frame and doorframe is chipped and damaged. The door is damaged with varnish peeling off. The shower curtain and barriers are damaged resulting in water escaping onto the main floor area resulting in a possible slipping hazard. The room is uncomfortable and unsightly. Service users spoken with were unhappy about the condition of the shower room. In the hallway and landing areas the wallpaper is damaged and in some areas is peeling in other areas the patterned wallpaper has been splashed with paint. Making these areas look unattractive. One bedroom has signs of water damage on the ceiling from a leak on the roof. There is no heating on the upper landing only a small oil filled radiator this area was cold. The fire escape leading from the first floor was very rusty with green moss growing this is a very slippery surface the manager stated the fire authority had already raised Evidence: this with her line manager. We advised her as a matter of safety this issue must be dealt with urgently. Some of the bedrooms were pleasantly decorated and furnished and reflected service users interests and tastes however the manager was unsure who had purchased the furnishings We advised her this information needed to be clarified to make sure the organisation and service users are clear who owned which pieces of furniture. Areas of the home visited were clean and tidy. There were no window restrictors fitted to outward opening windows on the first and second floors. We advised the manager to ensure risk assessments are carried out and were necessary restrictors are fitted as a matter of urgency. The manager informed us by e-mail on the 12/02/09 that risk assessments had been carried out and a request had been made to the housing association for restrictors to be fitted. The two lounge areas were pleasantly decorated and comfortably furnished and provided a homely environment the service users to spend time in. Service users have purchased communal garden furniture. There was no property agreement drawn up detailing if one person was to leave how they would be reimbursed for their share of the cost of the furniture. This leaves service users at risk of being financially exploited. The manager told us she has no control over the maintenance, decoration or furnishing of the home as she can only put requests to the housing association. Mencap who run the home appear to have little control over the ongoing maintenance of the building with essential maintenance only being carried out when a problem has already arisen. There is a lack of respect for individual choice in the home, with service users having limited control over the decoration, equipment, improvements or facilities being provided. Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Service users are supported by a trained and competent workforce resulting in some positive outcomes with regard to individualised care and support. Evidence: Mencap support the staff team to undertake training to enable them to support service users appropriately and safely this includes National Vocational Qualifications in care training, dementia awareness, person centred planning and a range of health and safety training courses. We discussed with the manager the need to make sure the staff teams training is up to date with refresher training organised prior to a qualification lapsing. We would advise the manager and the organisation to look at providing specific equality and diversity training to ensure services users individual lifestyle choices are acknowledged and supported. At the time of the visit the manager was in the process of drawing up a training plan to fit in with the corporate plan and identifying any specialist training such as epilepsy and dementia awareness for the staff team. Members of the staff team spoken with provided the following comments: I have worked here for over ten years I really enjoy working with the service users and supporting them to live their lives how they want to. I always knock on their bedroom doors this is their home and I am guest. When Im on the sleep-in I dont say Im off duty now you all need to go to bed I will Evidence: Wait until they decide to go to bed it would annoy me if someone told me I couldnt watch the end of a film in my own lounge. Mencap recruit their staff through their regional human resource department. We looked at a sample of records, which showed all the required safety checks had been made; staff had been issued with contracts and information about their job role. As an organisation Mencap involve service users in all aspects of the recruitment process. Having a robust recruitment processes offers service users confidence that they will be supported by people who have the necessary skills and suitable values to work with vulnerable people. The manager identifies training and development needs during supervision sessions. Members of staff spoken with during the visit confirmed this. I observed staff supporting service users sensitively and affectionately. Staff members spoken with demonstrated a good understanding of their roles and acknowledged that as service users needs change their approach and how they offer support is also changing and adapting. Resulting in service users being able to have confidence that the care and support being offered is flexible and responsive to their changing needs. Service users spoken with during the visit provided the following comments: The staff are good they help and look after me. I like it here I wasnt happy were I lived before. Staff spoken with said they enjoyed working for Mencap and felt supported and valued by the manager. Looking at the staffing roster showed service users supported by an adequate number of staff and also buys extra support from an outreach service provided by Mencap. This enables service users to maintain contact with people who supported them prior to moving into 7 Lingdale Road. Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Current management systems in place are not adequately robust enough that service users can be confident their health, safety and welfare is promoted and safeguarded at all times. Evidence: The manager is registered with CSCI and has been managing the service for over five years. She has gained the NVQ level 4 managers award and carries out periodic training to keep herself updated on care and management issues. Mencap have quality assurance systems in place including a visit and audit of the service on a monthly basis by an area manager and an annual self assessment review undertaken by the home manager. Examination of these documents and discussions with the manager indicates outcomes detailed in the review documents do not always match up with the actual outcomes experienced by service users. The statement of purpose and the service user guide do not provide all relevant and meaningful information to service users living at 7 Lingdale Road and those people who may wish to live there. Service users do not have contracts or term and conditions of residency leaving them legally vulnerable. The maintenance of the building is poor which has a negative impact on the quality of service users daily lives. We looked at a number of health and safety records including fire safety, gas safety check and electrical wiring safety assessment certificate. Not all checks and tests had been carried out within the agreed timescales which could put service users and the Evidence: staff teams health and safety at risk. The manager told us she would ensure all check are carried out and detailed records of the checks and assessments are kept. Are there any outstanding requirements from the last inspection? Yes  No  Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No Standard Regulation Requirement Timescale for action Requirements and recommendations from this inspection Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No Standard Regulation Description Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set No Standard Regulation Description Timescale for action 1 1 4 20/04/2009 The statement of purpose must accurately reflect the services and facilities to be provided by the home. It must also detail the facilities and services they are not legally responsible for. This is to ensure service users are able to make an informed decision as to whether 7 Lingdale Road can meet their needs. 2 2 14 As part of the assessment of 20/04/2009 service users needs undertaken prior to admission the condition of some of the facilities being provided should be considered in this process. And where appropriate as part of the decision making process. This is to ensure service users ability to maintain their independence is not limited by poor facilities. 3 5 5 22/06/2009 Each service user must be provided with the terms and conditions in respect of accommodation to be provided to them including as to the amount and method of payment and fees. This is to ensure service users rights as citizens are respected and protected. 4 7 12 Service users individual 25/05/2009 lifestyles choices must be acknowledge and supported. This is to ensure service users are supported to meet people within the community with similar lifestyles and interests. 5 15 12 Issues of equality and diversity in service users daily lives must be acknowledged and supported. 11/05/2009 This is to ensure service users can be confident their holistic needs are being valued and supported. 6 19 12 Service users health care needs must be effectively monitored and supported. 06/04/2009 This is to ensure service users receive affective and appropriate support from health care professionals in a timely manner. 7 20 13 Medication policies and 06/04/2009 procedures must be adhered to at all times. This is to ensure service users medications are administered safely and at the required intervals. 8 20 13 All areas where service users 06/04/2009 medications including food supplements are stored must be securely locked. This is to protect service users rights to privacy, confidentiality and to protect their health and well being. 9 24 23 A scheduled of works must 30/04/2009 be provided to the commission detailing environmental improvements to be made to 7 Lingdale Road within the next 12 months. This is to ensure service users live in a safe well maintained environment that meets their holistic needs. 10 39 24 Systems used to review the standard of service provided to service users must be reviewed. 18/05/2009 This is to ensure quality assurance systems focus on actual outcomes experienced by service users and promotes development and improvement in the service. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 9 Consideration should be given to reviewing risk assessments, which directly impact on service users health and safety more frequently than the current six monthly timescale. The complaints policy should be reviewed to ensure it is in formats that are meaningful to service users living at the home. The staff teams understanding and confidence with issues of equality and diversity should be assessed and training support offered if required. 2 22 3 35 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). 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