Inspection on 09/01/06 for Linsell House

This inspection was carried out on 9th January 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Linsell House 14/01/09

Linsell House 03/09/07

Linsell House 28/12/06

Linsell House 24/06/05

Linsell House 02/11/04

Linsell House 21/06/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Linsell House Ridgeway Avenue Dunstable Bedfordshire LU5 4QT Lead Inspector Linda Lilley Unannounced Inspection 9th January 2006 09:00 Linsell House DS0000032470.V275008.R01.S.doc Version 5.1 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 Linsell House DS0000032470.V275008.R01.S.doc Version 5.1 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. Linsell House DS0000032470.V275008.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Linsell House Address Ridgeway Avenue Dunstable Bedfordshire LU5 4QT 01582 699438 01582 477844 linselledfordshire.gov.uk 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) Bedfordshire County Council Mrs Geraldine O`Neill Care Home 16 Category(ies) of Learning disability (16) registration, with number of places Linsell House DS0000032470.V275008.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. Care Home LD - Learning Disability (Longstay) (12) LD - Learning Disability (Respite) (4) Period of stay for respite service users - max 6 weeks Gender: Male and Female Age: Over 18 years Service Users may also have additional physical disabilities Date of last inspection 24th June 2005 Brief Description of the Service: Linsell House is a local authority care home based in a residential area of Dunstable, providing long stay (12 beds) and respite care (4 beds) for up to 16 adults with profound learning and physical disabilities. Community nursing support is accessed as required. The accommodation comprises of three single storey interlinked bungalows (‘Green’, ‘Peach’ and respite), each with their own sleeping, living, bathing and kitchenette facilities. An industrial kitchen, staff rooms/offices, laundry room and communal living areas are also provided. The organisation of the home and the building is institutional in a number of aspects. To this end, a longterm plan for the home is re provision, but there are no known timescales for this. Community facilities and shops are situated reasonably close to the home, which is also in easy access of local public transport routes. Parking is to the front of the property, and a fair sized garden surrounds the buildings. Linsell House DS0000032470.V275008.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit took place over 7 hours, in the morning and afternoon of January 9th 2006. This visit followed a three hour period of review and preparation that included reviewing previous reports, reviewing information from other stakeholders, and documentation received in support of the process and preparing an inspection plan. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for Service Users and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The primary method of inspection used was ‘case tracking’ which involved selecting two Service Users and tracking the care they receive through review of their records, discussion with them, the care staff and observation of care practices. Seven Service Users, and ten members of staff were spoken to during the inspection visit. A partial tour of the premises was also completed and a review of the documentation and records required to be kept in a care home was also undertaken. This inspection report additionally addresses specific areas where requirements and/or recommendations were identified at the previous inspection. What the service does well: What has improved since the last inspection? COSHH items are now stored appropriately, and risk assessments completed. Designated Laundry assistants have been appointed and the door to the laundry room is now locked, and signposted Service Users rights to confidentiality are protected through appropriate use of the locked filing cabinets to store Service Users files. Linsell House DS0000032470.V275008.R01.S.doc Version 5.1 Page 6 Care plans with clear guidance regarding how to support the Service Users with some goals and targets have been set. The pictures used in the care plans are clear and there is some evidence of the Service User being involved in developing the plan. The procurement of a new cook, currently via an Agency, has led to the improvement in menu choices and meal content. The shower facilities within the respite area have improved. A new bath, which is more suitable for the Service Users has been ordered for Peach bungalow, and plans are available for the refurbishment of the bathroom. Further staff have undergone training in the administration of medicines, thus ensuring the policy for the administration of medicines can be adhered to. What they could do better: Provide adequate levels of permanent staff to ensure continuity of care for the Service Users and appropriate levels of senior staff to enable them to provide leadership and undertake development work, both with individual Service Users and Key workers. Ensure staff are using the care plans and support plans to direct Service Users activities, and are able to relate and document in the daily record the activities and interventions undertaken, with reference to the care/support planned. Ensure the individual Service Users rights to confidentiality and data protection are upheld in relation to the sharing of information with others, particularly in relation to respite care. Ensure that storage of food in the fridge and freezer is being stored appropriately. Review the method of recording fridge and freezer temperatures and the current practice of food sampling and storage Ensure that the results of quality monitoring e.g. Service Users or other stakeholders surveys, and the changes made as result of this are included in the Service User guide and the Statement of purpose and are readily available in the home. Review the strategies needed to enable the Service Users to integrate into the community, using public transport to access activities, for example, transport, drivers, staff shift patterns. Service User contracts should contain information regarding the payment for transport, if appropriate, and policy guidance should be available for service staff to follow. Ensure the Complaints procedure is accessible and appropriate for current Service Users and their relatives. Linsell House DS0000032470.V275008.R01.S.doc Version 5.1 Page 7 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. Linsell House DS0000032470.V275008.R01.S.doc Version 5.1 Page 8 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 Linsell House DS0000032470.V275008.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2.3.4. There are assessments in place for those Service Users accessing care and these are utilised to develop the Service Users plan and ensure staff have the necessary information they need to provide effective care. EVIDENCE: Whilst there has been no new Service Users admitted to Linsell House on a permanent basis since 2002, many new Service Users have accessed respite care. Staff spoken to could describe the process of transition for those Service Users accessing respite care, these included, evening visits with parents/carers, overnight stays, then long weekend stays prior to longer visits. The documentation seen within the respite unit contained clear assessment tools to enable an effective assessment of the Service Users needs. The longer stay Service Users files seen contained a needs assessment which included risk assessments of physical and mental health needs, however not all of these had been reviewed or contained appropriate staff signatures or dates. Prospective Service Users have access to the Service Users guide, which contains pictures and symbols to make it more accessible to the Service User and help inform the decisions regarding the suitability of the home. Linsell House DS0000032470.V275008.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6.7.9.10. Since the last inspection care and support plans have improved, they provide pictorial aids to support Service Users understanding and clear guidelines in the plan for staff to follow. However the three file system in use does not encourage staff to relate outcomes to planned support. The system for storage of Service User information is robust, however the arrangements for sharing information about Service Users who have accessed respite care is not based upon individual Service Users wishes. EVIDENCE: Care and support plans seen contained a photograph of the Service User, and assessments regarding moving and handling, mobility and communication, with clear guidance regarding any interventions required to reduce the risks to the Service User. Key workers had been identified for each Service User. The care and support plans also contained some clear guidance for staff regarding behaviours identified, possible triggers and action to be taken by staff. The current system of three separate working files, Care plan, support plan and “ daily notes” file seen did not provide a user friendly way of obtaining information, planning activities and interventions and then reporting on them. There was little evidence in the daily notes, that staff are using the care plans Linsell House DS0000032470.V275008.R01.S.doc Version 5.1 Page 11 and support plans to direct and support Service Users activities, and are then able to relate and document in the daily notes the activities and interventions undertaken, and any movement towards goals and targets set. Not all plans seen contained evidence of any Service User or family/friends/advocate involvement and one of the plans examined contained no dates or signatures of the key worker or any indication of any discussion with the Service User. The filing cupboards within the bungalows and the cupboard within the “medicines room” containing Service Users files were all locked and staff spoken to were able to discuss the rationale for this. There was no evidence of any individual assessment or consent from Service Users in respite care regarding the sharing of personal and intimate information regarding their stay. The current practice is to photocopy all the notes and give them to the parent/friend, on discharge. Linsell House DS0000032470.V275008.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12. 13. 15. 17. There have been some improvements in the facilitation of leisure activities, personal development opportunities and the diet provided for Service Users, however access to these opportunities continues to be influenced by staffing levels and availability, transport and shift patterns. EVIDENCE: Discussion with managers and staff indicated Service Users contracts have not been reviewed since the last inspection, to include the agreed financial contributions required from the Service User for leisure activities and transport (previous requirement). The Service Users files examined and some files from the respite area, did contain evidence of a range of activities, particularly over the Christmas period, including, aromatherapy, carol signing, disco, Christmas shopping, pub for lunch, art work, friends visiting, watching football on TV. However there was no evidence of activities specifically aimed at supporting the Service Users towards achievement of the goals identified within the care/support plan. Most Service Users now have concessionary travel cards, for public transport, but staff indicated it is difficult, particularly when on an early shift, to prepare Service User to go out, wait for public transport, to and from the home, and undertake activities, within the time they were on duty. The issue of insufficient drivers for the homes own transport was also raised and staff said they thought Service Users whose key workers were not minibus Linsell House DS0000032470.V275008.R01.S.doc Version 5.1 Page 13 drivers were disadvantaged. Staff and the Service Users spoke about friends and boyfriends and staff encouraged them to communicate about their meetings and plans. Discussion with Service Users, staff and the newly appointed cook highlighted within the previous two weeks the menu had improved, more choices, better quality, and not just sandwiches for tea, hot snack e.g. beans on toast was available The cook provided information re menu planning including home made cakes, fresh vegetables and future plans to encourage the Service Users to be as involved as much as they could. Staff said they were producing pictures of food, so the Service Users could make choices; these were not available during the inspection. There was no evidence within the support plans seen of Service Users likes and dislikes regarding food. All Service Users were offered a cup of tea and biscuit/cake as they returned to the home. The cook had prepared an order for fresh vegetables for the next day, however there was no one on duty who could access the computer system to enable this to be actioned, and the Assistant Manager indicated the member of staff who could do this was not available for the next 24 hours. Linsell House DS0000032470.V275008.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18. 20. 21. The lack of permanent staff does not always enable effective continuity of care and support for personal support and care for Service Users. The increase in the number of staff trained in the administration of medicines has ensured that Service Users medicines can be administered in accordance with the homes policy. EVIDENCE: Review of the rota’s highlighted that there was a high level of sickness and absence, and the home also had staffing vacancies, for example the team leader position, resulting from the promotion to Assistant Manager. 12 agency staff were being employed in the current week and 7 had been booked for the following week, discussion with two Service Users confirmed they didn’t like “ a different person” all the time to care for them. Staff had provided information to the Assistant Manager that they did not feel an agency member of staff on duty the previous day had been competent to provide personal support for the Service Users. The Assistant Manger discussed this with the Agency concerned. Review of the rota also indicated that there were always two trained staff in each bungalow trained in the administration of medicines. 16 of the 18 staff on the rota were highlighted as “medication trained”. Service Users files seen contained written evidence of discussion with Service Users family regarding their wishes re dealing with terminal illness and death. Linsell House DS0000032470.V275008.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22. 23 The current complaints procedure leaflet, is not in a format suitable for the Service Users and would not be helpful for Service Users who wished to complain. Arrangements for protecting Service Users are in place, and there are clear systems of reporting and monitoring any incidents or accidents. EVIDENCE: The complaints leaflet provided to the inspector in response to a request to a member of staff for information regarding how Service Users or families would know how to complain, was a standard complaints procedure provided by the Social Services Department, it was not specific to Linsell House and was not user-friendly for Service Users. Appropriate systems and protocols were in place for reporting incidents relating to the protection of vulnerable adults. Checking of the systems found the accident book was up to date and the Assistant Manager had signed and investigated all reported incidents and accidents. Body charts were also completed for any Service User who presented with any unexplained bruising and this was recorded within the Service Users file and within the accident/incident report and followed up by the Assistant Manager. COSHH items are now stored appropriately, and risk assessments completed. Disposable gloves are stored in a locked cupboard, with the incontinence products, and one box stored on a high shelf in the bathroom in the respite area. Designated Laundry assistants have been appointed and the door to the laundry room is now locked, and signposted. Linsell House DS0000032470.V275008.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24.27.30. The home is clean and tidy, and the standard of décor has improved in some areas since the last inspection. However there are still some areas, which do not provide appropriate facilities at the required standard for the Service Users. EVIDENCE: Fire log showed the fire alarm testing and fire drills were up to date, with a report produced after each drill. A risk assessment has been completed, (1/11/05) in relation to the propping open of some doors to enable appropriate care of the Service User and staff were able to discuss this and the actions required. (Previous requirement) A letter from the Bedfordshire Fire Authority (1.12.04) provided advice regarding holding doors open with magnetic door releases. This is held within the Linsell House fire information file. A tour of some of the bedrooms, communal areas and bathrooms and toilets provided evidence that the home was clean and tidy, despite the difficulties with the state of repair of some of the bathrooms, and general areas such as broken plasterwork in link corridors and general scuffing of most walls and skirting boards. Linsell House DS0000032470.V275008.R01.S.doc Version 5.1 Page 17 Orders were seen for a new bath and with a trolley and with a tracker hoist for Peach bungalow, however no firm date for refurbishment of the bathroom was available and the current bathroom in Peach bungalow is inappropriate, has water damage from previous floods, and does not meet Service Users needs. The shower unit in the Respite bungalow has been repaired and now provides hot water at an appropriate pressure. The snooze room contains appropriate equipment, including a low level plinth mattress, and sensory screens and projectors, however the staff reported it was not well used as it was difficult to get wheel chairs in, it was full of arm chairs at the time of the visit, and that staffing levels mean that there is not always a member of staff available to supervise Service Users. There has been some replacement of carpets, some decorating of communal areas and some replacement furnishings, in some areas. Generally Service Users bedrooms seen during the tour of the home were furnished appropriately and contained many personal items. Linsell House DS0000032470.V275008.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32. 33. 35. There has been a little progress in addressing the staffing sickness and absence, at a strategic and planning level, however there are still high levels of sickness and absence within the permanent staff and this situation is having a detrimental effect on the provision of consistent and flexible support for the Service Users. Permanent Care staff on duty have the competencies or are undergoing training to obtain the competencies require to provide effective care and support to the Service Users. EVIDENCE: The staff available for work was depleted on the day of the visit, by the following circumstances, Senior Manager, compassionate leave, 1. Assistant Manager, sick leave, Team leader, sick leave, two staff on maternity leave, two staff seconded to training programmes and one vacancy for team leader post (Peach bungalow). The rota for the week highlighted that 12 agency staff would be used this week and 7 were currently booked for the following week, to meet the required staffing levels. Discussion with Resource Manager, who was visiting the home and providing some managerial support to the Assistant Manager and acting team leader on duty, highlighted that arrange of intervention were being instigated to address the high levels of sickness and absence, these included sickness and absence Linsell House DS0000032470.V275008.R01.S.doc Version 5.1 Page 19 monitoring, trend reporting, return to work interviews, with support being obtained from Human Resources department when any action was required. Some staff on duty reported they had up to 30 hours “time owing” logged due to staff shortages and would find it difficult to recoup this time. The Assistant Manager was seen to spend a high proportion of his time during the seven hours of this inspection contacting the staffing agencies, individual members of staff and juggling rotas. Discussion with the permanent staff on duty indicated many had completed NVQ level 2 or 3 in care. The NVQ provider was supporting two staff members on the day of the inspection visit. Two full time staff have been seconded to undertake Social Worker training programmes, and staff spoken to felt that this was commendable, but with hind sight it may have been over ambitious for the home to support two staff at the same time. The competence of an agency member of staff employed to deliver care has been mentioned in standard 18. Evidence was seen of staff having undergone training in the administration of medicines and some staff having completed an update on moving and handling techniques, with a date planned for those staff that had not attended in November and December 2005. Linsell House DS0000032470.V275008.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38. 39. 42. The manager has begun to develop a range of leadership interventions and implement changes to improve the quality of care for the Service Users, however this is hampered by the lack of consistent staffing. Since the last inspection some mechanisms have been instigated to ensure the health and safety of the Service Users and staff, however these are not fully compliant with the standards required. EVIDENCE: Staff on duty during the visit reported that the Manager was approachable, fair and would follow up any issues with staff. The Assistant Manager and Acting Team leader, from observation and discussion during the visit, did not seem to have the time to continue any leadership/project developments in the absence of the Manager due to current staffing levels and they spent a lot of time contacting staff and rearranging the rotas. The staff on duty could not provide any evidence of any quality assurance mechanises in place that seek the views of the Service Users or their families. There were no results of any Service User, family or other stakeholders surveys (e.g. GP’s, teachers, chiropodists, District Nurse, parent or carers group), published within the home. Linsell House DS0000032470.V275008.R01.S.doc Version 5.1 Page 21 There was evidence of some staff having undertaken Moving and Handling training in December 2005, however 6 staff had not yet completed this. Further training was in the process of being booked, to be completed by February 1st 2006. The system for monitoring the fridge and freezer temperatures in the kitchen and shed, are not robust. Records showed the fridge temperature recorded as –5 degrees for every recording in the previous week, which on examination proved to be 5 degrees, the recording of the temperature of the freezers did not indicate which freezer the temperature related to, the kitchen or the shed. There were also food samples in the fridge, in open containers, which would have been contaminated by other food products, should they have been required for examination. Evidence of electrical equipment risk assessment and checking was seen. Fire log examined and up to date. Notes in staff communication book seen re need to ensure appropriate restraints and locks for wheelchairs are available in the taxis booked for Service Users. Linsell House DS0000032470.V275008.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 2 3 2 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 1 23 2 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 1 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 1 34 x 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 x 2 1 LIFESTYLES Standard No Score 11 x 12 1 13 1 14 x 15 3 16 x 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 x 2 3 x 2 1 x x 2 x Linsell House DS0000032470.V275008.R01.S.doc Version 5.1 Page 23 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA3 Regulation 18.1 Requirement The registered manager must ensure the staff individually and collectively have the skills and experience to deliver the service that the home offers to provide. The registered manager must ensure staff are using the care plans and support plans to direct Service Users activities, and are able to relate and document in the daily record the activities and interventions undertaken, with reference to the care/support planned. The Registered Manager must ensure that an individual assessment and obtaining of consent from Service Users in respite care regarding the sharing of personal and intimate information. The Registered Manager must review the strategies needed to enable the Service Users to integrate into the community Service Users contracts must have the agreed financial contributions required from the Service User for leisure activities DS0000032470.V275008.R01.S.doc Version 5.1 Page 24 Timescale for action 01/04/06 2 YA6 15.1 01/05/06 3 YA10 15.2 01/04/06 4 YA13YA12 16.2 01/04/06 13 Linsell House and transport. (Previous requirement) 5 YA18 12 The Registered manager must provide levels of permanent staff to ensure personal support to be delivered in a way the Service users prefer. The Registered Manager must ensure the Complaints procedure is accessible and appropriate for current Service Users and their relatives. 01/05/06 6 YA22 22.2 01/05/06 7 YA27 12.13.22. 8 YA33 18 The Registered Manager must 01/04/06 ensure the bathing facilities in Peach bungalow meet the required standard for Service Users. The Registered Manager must 01/05/06 ensure the numbers and skill mix of staff on duty can support Service Users needs. 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 YA17 YA39 Good Practice Recommendations Revise the systems for enabling staff to order fresh food for Services Users. Ensure that the results of quality monitoring e.g. Service Users or other stakeholders surveys, and the changes made as result of this are included in the Service User guide and the Statement of purpose and are readily available in the home. Linsell House DS0000032470.V275008.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Linsell House DS0000032470.V275008.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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