Inspection on 08/05/07 for Linkage Cluster 3

This inspection was carried out on 8th May 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Linkage Cluster 3 16/09/05

Linkage Cluster 3 03/05/05

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Linkage Cluster 3 20 Pelham Road Grimsby DN34 4SU Lead Inspector Ms Wilma Crawford Unannounced Inspection 8th May 2007 09:30 Linkage Cluster 3 DS0000061287.V336283.R02.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 Linkage Cluster 3 DS0000061287.V336283.R02.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. Linkage Cluster 3 DS0000061287.V336283.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Linkage Cluster 3 Address 20 Pelham Road Grimsby DN34 4SU 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) 01472 241044 Linkage Community Trust Edward James Wright Care Home 14 Category(ies) of Learning disability (14) registration, with number of places Linkage Cluster 3 DS0000061287.V336283.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Devonshire Avenue. The downstairs bedroom is to become staff sleepin room and the upstairs bedroom 1 (currently used as staff sleep-in room) to become a single bedroom for service users. This is to take place when service user currently accommodated in the downstairs bedroom leaves the home or earlier with the agreement of the service user. (Regulation 23 (2) (e)). Linkage cluster 3 may accommodate a maximum of 5 service users aged 16-17 years of age conditional on there being no service users over the age of 25 years at the home. (Suplementaty standards for care homes accommodating young people aged 16 and 17 will apply). 16th September 2005 2. Date of last inspection Brief Description of the Service: Linkage cluster 3 comprises two houses both situated in residential areas of Grimsby. 20 Pelham Road is close to Grimsby town centre and 16 Devonshire Avenue is close to Peoples Park. Both houses are in keeping with surrounding properties. Both houses are two storeys and have garden areas. Pelham Road provides accommodation for 8 service users. On the ground floor is one s ngle bedroom that has an en-suite, a double bedroom, lounge, dining room, domestic style kitchen and separate toilet. Upstairs there is a bathroom with toilet, a shower room with toilet, one single bedroom, two double bedrooms and a staff sleep-in room. Devonshire Avenue provides accommodation to 6 service users. On the ground floor there is a dining room, lounge, domestic style kitchen and shower room with toilet. Upstairs has two single bedrooms’ two double bedrooms and a bathroom with shower over bath and toilet. There is also a staff sleep – in room. The houses provide furniture and fittings that are of a domestic style. Information is made available to students in the service users’ guide and statement of purpose. Linkage Cluster 3 DS0000061287.V336283.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over seven hours including preparation time. Three students and three staff were spoken with during the inspection. The manager and Residential Services Manager were available throughout. The main method of inspection used was called case tracking which involved selecting two students and tracking the care they receive through the checking of their records, discussion with them, the care staff and observation of care practices. The premises were looked at and the records of two students and one staff were inspected. The comments and views of people spoken with are included within this report. A Pre Inspection Questionnaire asking for information about home was sent out before this visit and information from this was included as part of the inspection process of this service. 12 students, 1 professional and 2 staff surveys were completed and returned. The comments from these are also included in the report. The fees charged are detailed on individual contracts, which details their contract as, provided by the learning and skills council, who fund students accessing the linkage college provision. What the service does well: Linkage Community Trust provides an excellent service for young adults with a learning disability and other needs. It is well managed at all levels from the directors to the support workers. The primary aim of the college is to enable the young people to develop as much independence as possible, whilst helping them to be more confident. They provide a wide range of educational college courses and training in life skills, they also provide training on the use of buses and road safety. Policies and procedures (rules) that are regularly reviewed and changed in order to promote students rights and best interests and ensure that the staff have the information to do their jobs properly. Linkage actively promotes students as individuals and ensures they are listened to and that they have a say in how they live their lives. There is a very active student/learner council and regular student meetings. Students are at the heart of the organisation and their views/wishes are taken into account by the use of questionnaires, learner council meetings and by managers and staff who make sure they are involved. Students and their families are given detailed information about linkage so that they are able to make a choice about whether to go there or not. The information provided is available in appropriate formats. Students have an in depth assessment prior to coming to college. Individual care plans are detailed and comprehensive and are developed with students. Linkage Cluster 3 DS0000061287.V336283.R02.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. Linkage Cluster 3 DS0000061287.V336283.R02.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 Linkage Cluster 3 DS0000061287.V336283.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience excellent outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People accessing this service undergo a thorough assessment prior to admission and are provided with the necessary information to enable them to make an informed choice EVIDENCE: Students are assessed for their placement at linkage by the Linkage Transition team. The team provide parents with a copy of the document ‘Information for Parents’ which covers all aspects of college life including development, health and welfare, consent forms, finance, college and student charter etc. The Transition team visit the student at home/school and students also go to Weelsby Hall for a 3 or 5-day residential placement for assessment. The assessment also includes the student’s social worker from their home area, school, educational psychologist, medical professionals and the connexions service. Any potential restrictions/limitations are discussed and agreed at this time and any students whose needs the college can’t meet will be refused admission. Pelham and Devonshire support students at programme levels 1 & 2.***** Linkage Cluster 3 DS0000061287.V336283.R02.S.doc Version 5.2 Page 9 Students confirmed that they had visited the college prior to moving in and had had the opportunity to visit the houses that they had been offered accommodation in. Linkage Cluster 3 DS0000061287.V336283.R02.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 &9 People who use this service experience excellent outcomes in this area. We have made this decision using a range of evidence, including a visit to this service. People are empowered to make decisions and are consulted on in all aspects of their lives. EVIDENCE: Care plans are detailed and comprehensive. Students spoken to confirm that they are encouraged to participate in the development of their own care plan. Each student writes a pen picture about himself or herself, which is included in their care plan. Samples of care plans were examined as part of the inspection process and had been developed to cover all aspects of the students assessed needs and were kept under constant review. Students are enabled to be as independent as possible and this was confirmed by talking to staff, students and families, who stated that the colleges main aim was to ‘promote independence’. A professional commented that following substantial collation of information on initial assessment, this is followed correctly. Risk assessments were in place for any areas that posed a risk to students and measures put in place to minimise the risks, i.e. personal safety, road safety Linkage Cluster 3 DS0000061287.V336283.R02.S.doc Version 5.2 Page 11 and leisure activities. Students are actively encouraged to be involved in the development and review of risk assessments. All students had a key worker and were able to tell the inspector who this was and explain what their specific role was. Key workers play an active role in ensuring that students are familiar with the content of their care plan and any changes are made in consultation with the individual. Students confirmed this. Linkage Cluster 3 DS0000061287.V336283.R02.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): 12,13.15 16 & 17 People who use this service experience excellent outcomes in this area. We have made this decision using a range of evidence, including a visit to this service. Students have extensive opportunities for leisure activities, are supported to maintain relationships and have their nutritional needs well met. EVIDENCE: Students are offered a healthy diet. Attention is paid to student’s specific dietary and cultural needs. The students have a weekly house meeting to plan the menu for the week and agree who should be involved in the shopping and preparation of meals. Individuals are encouraged to be involved in the preparation of meals, with the necessary support that they need from staff. The students were able to give examples of how they supported fellow students in pursuing their individual needs whether these were cultural or specific dietary needs. This was evidence of encouraging and enabling the students’ to develop their understanding and tolerance of cultural needs. Students were looking forward to one of the students’ birthdays and a visit Linkage Cluster 3 DS0000061287.V336283.R02.S.doc Version 5.2 Page 13 from their family who were organising a party in one of the houses to celebrate the occasion. Alternatives are always available for everyone and students were able to give examples of individuals likes and dislikes and what they planned to have instead for their meal. Students are able to invite friends to their accommodation and often arrange barbeques and joint outings enabling friends to spend time together. Staff focuses on the individual person and ensure that they are listened to and have a say in their daily lives by promoting an active student/learner council and regular meetings in the houses. There is an active learner council, supported by an advocacy worker, house meetings once a week and leisure meetings. Students were able to explain how they decided as a group what the menu would be for the week, how their rooms would be decorated, and how they are included in staff selection. Student’s social, emotional; communication and independence skills are developed and maintained by the implementation of the 24-hour curriculum. Linkage has recently introduced a further support network in the form of ‘A Quiet Place’. A Quiet Place offers a six week intervention programme which focuses on improving the learners emotional intelligence skills and developing their awareness of how stress can affect them physically. They also receive a hand massage or foot spa which gives the learners the opportunity to manage their stress levels more effectively. Some students have secured work experience placements and all students participated in leisure activities in the community e.g. bowling, swimming, shopping and pursue their own hobbies. Students told the inspector that they enjoyed ice skating, football and going to town. Planned trips were organised at weekends and for the bank holiday, Duke of Edinburgh camping trip, cinema, cue world, meals out, shopping and BBQ’s. Transport is provided by the college in the form of mini buses, people carriers and company cars, however the emphasis is on the use of public transport and independent travel. Professionals confirmed that the staff closely monitored personal issues that may affect relationships within the house. Linkage Cluster 3 DS0000061287.V336283.R02.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 &20 People who use this service experience excellent outcomes in this area. We have made this decision using a range of evidence, including a visit to this service. Students’ physical and emotional needs are met, by the provision of a wide range of healthcare professionals and outside agencies. EVIDENCE: Records examined confirmed that students had access to a wide range of health professionals e.g. psychiatrist and psychologist, speech and language therapist and visual impairment specialist, there is also a registered nurse on the college campus that students can book an appointment with. Students are enabled to visit the GP, audiologist, and dentist and attend any outpatient appointments otherwise relatives can facilitate this when students go home. Linkage has robust medication policies and procedures that include receipt, storage, administration and disposal of medication. Students who wish to self medicate are encouraged to work toward this with a graduating self-medication programme. The college nurse will assess the student prior to commencement and a risk assessment is undertaken. Facilities are made available to students to lock their medication away. The medication system was examined. Linkage Cluster 3 DS0000061287.V336283.R02.S.doc Version 5.2 Page 15 Medicines were found to be stored appropriately and records were well maintained and complete. The GP regularly reviews students for their medication and the college nurse checks the systems in the houses on a regular basis, the local pharmacist also regularly reviews the systems. The manager of the home has a role in development of medication policies and procedures and staff training in medication. He is also currently involved with the residential Services Manager in developing a new system where after further training, and review of procedures the responsibility for ordering medication will lie with the home. Linkage Cluster 3 DS0000061287.V336283.R02.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): 22&23 People who use this service experience excellent outcomes in this area. We have made this decision using a range of evidence, including a visit to this service. Students are consulted about all aspects of their college lives and are safeguarded from harm. EVIDENCE: All people spoken with including relatives, staff and the people who use the service were aware of how to make a complaint. Linkage has a complaints policy/procedure that includes, which is available in symbols, audiocassette and DVD. Each student has a copy of this. (kept in their care plan) and those spoken with confirmed this. Surveys returned confirmed that people are aware of this procedure. Two complaints have been made in last 12 months; these were resolved promptly to the complainant’s satisfaction. The risk of abuse to people is minimised through robust protection procedures being in place. Everyone spoken with said they felt safe and protected from harm. Linkage has a Protection of Vulnerable Adults and Child Protection procedure, which identifies a key person within the college for all referrals made. Staff spoken to were clear about their responsibilities within the POVA /complaints procedures. Minor issues were dealt with through the house meetings and minutes were seen to evidence this. More serious issues were taken to the learner council and a mechanism is in place for responding to these areas of concern and/or complaint. All students have responsibility for their own personal allowances and are offered lockable facilities to store their money if they wish. Linkage Cluster 3 DS0000061287.V336283.R02.S.doc Version 5.2 Page 17 Linkage Cluster 3 DS0000061287.V336283.R02.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24&30 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of available evidence, including a visit to the service People who use this service are provided with a safe environment that is clean, comfortable and well decorated. EVIDENCE: Pelham and Devonshire comprises of two houses. Both houses offer accommodation over two storeys and have front and rear gardens. The houses offer a small homely type of accommodation for students living there. Extensive work has been completed throughout the hall including the fitting of new kitchens, redecoration of bedrooms, communal areas, new carpeting, new furniture, new sofa’s, total refit of toilets, shower rooms and bathrooms, which has improved the home environment considerably. The inspector was informed that the registered manager keeps a maintenance book. Any action relating to maintenance is recorded there and any action taken or the date the task was completed. Any major works are undertaken on a rolling programme on a priority basis. The organisation have more maintenance workers employed, ensuring that repairs and redecoration can be dealt with promptly. Students have been involved in the improvements, Linkage Cluster 3 DS0000061287.V336283.R02.S.doc Version 5.2 Page 19 choosing, colours, furnishings, pictures etc. They also approached the manager to purchase some beanbags, which was duly done. A long-term plan has been developed to reduce the double rooms in the building. Students are fully consulted about sharing a room and their wishes are respected and recorded in their decision making record. The students have responsibility for cleaning in the house and are supported by staff to do this.The home was found to be clean, tidy and odour free. Students described the home as ‘spot on.’ Linkage Cluster 3 DS0000061287.V336283.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 & 35 People who use this service experience excellent outcomes in this area. We have made this judgement using a range of evidence, including a visit to the home. People are supported by a competent, skilled staff team, who are wellsupervised and available in sufficient numbers to meet individual’s needs. EVIDENCE: Support levels are provided in line with assessed needs of individuals. People in this service are cared for by sufficient staff, who are extremely competent, skilled and knowledgeable in the area of learning disabilities. The registered manager has a training and development plan for the staff team that clearly identified staff training needs and all staff had an individual training and development action plan that was completed annually. A wide range of training is provided by linkage and included mandatory training, HIV/Aids, POVA and child protection, diabetes, aspergers, autism, makaton, competence to drive the mini bus, administration of medication, epilepsy, religion and culture, confidentiality, whistle blowing, every child matters, principles of care, managing challenging behaviour and human rights. Although all mandatory training is up to date staff gave examples of on some occasions having to wait longer than they would prefer to access certain training, as much of it is done during training weeks. Linkage Cluster 3 DS0000061287.V336283.R02.S.doc Version 5.2 Page 21 A discussion with Linkage development team was held to ensure that the residential staff could access the required training, as it is needed. It was agreed that this could be resolved easily; by staff recording more than one their preferred dates of training on their request form. The organisation holds the investors in people Award. The majority of the staff team are now registered to complete NVQ level2 and the managers are now qualified assessors. Additional support is also available through the Organisation NVQ assessors. Progress has been made and staff spoken with are keen to complete the award. A small number of staff has completed the award The staff team are well supported, records examined and discussions with staff confirmed that formal supervision is provided at least 6 times a year, sometimes more and informal supervision as and when needed. The manager and residential service s mangers oversee the recruitment procedure, an application form, two written references a police check and a protection of vulnerable adults and children checks are undertaken prior to a person starting employment. The risk of harm to people is minimised due to the stringent procedures in place. One staff file was inspected, and found to be up to date. A recruitment procedure is in place and the manager is very clear about the calibre of staff he wishes to recruit in order to be able to meet individual needs. Staff are all given induction training when they start working in the service. Linkage has a comprehensive induction pack, which staff work through over a number of weeks. This looks at care practices, expectations of staff and covers mandatory training. Staff spoken with confirmed this training had taken place, and individual training files were available to evidence this. The registered manager and deputy oversee both houses, Independence tutors and learner assistants are available as determined by assessed need. Independence tutors sleep in to provide students support throughout the night. Students described the staff as being friendly, supportive and approachable but most of all as having wonderful kindness. All the students spoken with, thought the staff team were great. Linkage Cluster 3 DS0000061287.V336283.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 & 42 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service are safeguarded and strong management promotes independence and choices. EVIDENCE: The registered manager of this service is an excellent individual with a genuine regard and philosophy of caring for people with learning disabilities, where person centred care is of paramount importance, and the needs of individuals are considered and reflected upon in detail. The manager has achieved the Registered Managers Award, an Assessors Award and is close to completing NVQ at level 4. He continually strives to improve the service and competently and conscientiously supports his capable staff team. A deputy post has recently been created to support the manager and the further progression of the service. Linkage Cluster 3 DS0000061287.V336283.R02.S.doc Version 5.2 Page 23 Staff spoken to stated that the registered manager is “very dependable,supportive and thorough.”, “He is professional and calm and always on top of the job”. Staff commented that they felt valued within the organisation and by their manager. The health and safety of people in the service is extremely important. There are designated fire officers and maintenance staff who are responsible for minimising risk of harm to people. Weekly fire drills take place and a fire risk assessment has been completed. Doors automatically close if the fire alarm goes off, and staff are familiar with the Linkage fire procedure. Pictorial formats of the fire procedure are displayed throughout the home. Mandatory training was discussed; evidence in individual files of moving and handling, fire safety and infection control was evident A range of certificates were highlighted in the pre-inspection questionnaire and contracts are in place for maintenance of the emergency lighting, fire safety equipment and portable appliance testing. Linkage has a corporate Health and Safety policy and procedures to ensure the safety of students, staff and visitors. All areas are risk assessed, this includes both environmental and task/activities. They have been awarded the 3 Star British Safety Council Award. A Corporate Quality Monitoring system (EFQM) and a College Quality Manager who co ordinates and leads on quality issues is available within the organisation. An annual plan is produced that provides the framework for QA activity including surveys, audits and appraisals. The organisation is currently looking to update this system. Linkage produces an Annual Review document and regular newsletters. All of which were seen. A monthly analysis of accidents, is completed by the manager Linkage Cluster 3 DS0000061287.V336283.R02.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 Linkage Cluster 3 DS0000061287.V336283.R02.S.doc Version 5.2 Page 25 CHOICE OF HOME Standard No Score 1 X 2 4 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 4 33 X 34 4 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 4 15 X 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 X 4 4 X 4 X 4 4 X Linkage Cluster 3 DS0000061287.V336283.R02.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA32 YA32 Good Practice Recommendations The organisation should ensure that identified training for new starters is made available within three months of their appointment. The registered person must ensure that 50 of staff are qualified to NVQ level 2. Linkage Cluster 3 DS0000061287.V336283.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Linkage Cluster 3 DS0000061287.V336283.R02.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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