Inspection on 30/01/07 for Lisieux Hall

This inspection was carried out on 30th January 2007.

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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lisieux Hall 15/11/07

Lisieux Hall 01/03/06

Lisieux Hall 23/11/05

Lisieux Hall 26/11/04

Lisieux Hall 10/05/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Lisieux Hall Dawson Lane Whittle-le-Woods Chorley Lancashire PR6 7DX Lead Inspector Mrs Marie Matthews Unannounced Inspection 30th January 2007 10:00 Lisieux Hall DS0000025567.V323075.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lisieux Hall DS0000025567.V323075.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lisieux Hall DS0000025567.V323075.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lisieux Hall Address Dawson Lane Whittle-le-Woods Chorley Lancashire PR6 7DX 01257 266311 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) Brothers Of Charity Services Lisa Fitzsimmons Care Home 32 Category(ies) of Learning disability (32) registration, with number of places Lisieux Hall DS0000025567.V323075.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 32 service users to include:*Up to 32 service users in the category of LD (Learning disability). 1st March 2006 Date of last inspection Brief Description of the Service: Lisieux Hall is located in a rural setting approximately half a mile from the A6, which is one of the main roads linking the towns of Preston and Chorley. It is also approximately 1 mile from the A49, one of the main roads linking Preston and Wigan. Because of its rural setting, access to local facilities such as post office, shops and public houses is not easy, with the nearest being a half-mile away. Service users access these by walking, or, where appropriate, an escort is provided from the home. A wider variety of shops can be found in Chorley, which service users access via public transport, taxi, or transport provided by Lisieux Hall. Lisieux Hall is run by the Brothers of Charity and is part of a wider service, which also provides day care, supported employment, and domiciliary services to service users with learning disabilities in the Chorley & South Ribble areas. Lisieux Hall is the administrative centre for the Brothers of Charity Services in Lancashire and has additional resources on site. The Lisieux Hall site comprises of 8 residential units (with 5 units in use at the time of the inspection). The home is registered to accommodate a total of 32 service users with a Learning Disability, with some service users having nursing needs. There were 26 people resident at the time of the inspection and there are plans to reduce the numbers of service users accommodated as appropriate housing in the community becomes available. Service users also have access to a range of work, educational and leisure opportunities in the local area. At the time of the key inspection the weekly fees for this service range from £413.00 to £1495.50 dependant on the needs of the individual. Additional charges are made for hairdressing, holidays and transport. Lisieux Hall DS0000025567.V323075.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key unannounced inspection was conducted at Lisieux Hall on 30th January 2007. The inspector looked at records, talked to the person in charge, six staff and three people who lived at Lisieux Hall; the inspector also had a look around the home to check if it was suitable and safe for people to live there. One visitor also provided some information about the home. There were twenty-six residents living in the home on the day of the inspection. What the service does well: All residents at the home had an individual plan; the plan contained lots of useful information about them that would help staff to look after them properly. The person in charge made sure the individual plans were up to date and had been filled in properly to show what sort of support residents needed from staff. The individual plans showed the inspector that the residents, their relatives and friends and other useful people had been involved in decisions about care. One visitor said that staff had told her about important changes. One relative said she was always made to feel welcome when she came to the home. Staff said visitors could visit the home at any time and could join in with the activities of the home. Each resident had a special member of staff who they could spend time with; this person was called a key worker. Residents had an activity plan that showed they were able to take part in lots of different activities that they had chosen. Staff had collected lots of information about what resident’s liked to do and this helped when activities, work and outings were being planned. Staff said residents were involved in choosing the meals for each week; this helped to make sure that everyone enjoyed them and that the meals were suitable and healthy. Staff had been shown how to look after medicines and how to make sure residents were given the right medicines to keep them well. Lisieux Hall DS0000025567.V323075.R01.S.doc Version 5.2 Page 6 Staff knew how to keep residents safe and protect them from harm; people knew who to go if there was something wrong. Residents lived in a clean, safe and comfortable home. Each resident had their own bedroom; the bedrooms were bright and cheerful and residents had helped to choose their own furniture and wallpaper. The home made sure that staff had been taught how to look after residents properly. One resident said staff were ‘nice people’ and he was ‘looked after’. One member of staff said ‘the training is excellent’ another said ‘we are given the training we need to do the job properly’. Staff said there were enough staff to make sure people were looked after and they were able to spend time with residents who needed their attention. Most of the staff had worked at the home for a long time and had got to know the residents and their families really well. One member of staff said ‘ I love working here’. The home made sure that people were safe by making sure all the proper checks were done before taking on new staff. Regular checks were done to make sure the home was running well and people were asked to give their opinions on this matter. What has improved since the last inspection? What they could do better: The staff needed to make sure that all details about how to look after residents were included in the individual plans; this would make sure that residents were looked after properly. There should be better records to show what meals people have eaten and to make sure residents were always given a varied and healthy diet. Information about medication should be put on each unit to make sure staff had clear and safe instructions to follow. Lisieux Hall DS0000025567.V323075.R01.S.doc Version 5.2 Page 7 There was a team of people who mended things when they were broken; the home needed to make sure that if anything needed mending it was done quickly this would make sure that the home stayed a nice, safe place for residents to live in. Not all of the units had filled in the paperwork properly; this needed to be done to show that people were safe from harm. 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. Lisieux Hall DS0000025567.V323075.R01.S.doc Version 5.2 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 Lisieux Hall DS0000025567.V323075.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There had been no new people admitted to the home. However individual plans were generated from assessment information and contained detailed information about resident’s needs and aspirations. EVIDENCE: There had been no new residents admitted to the home since the last inspection. Some residents had moved out into the local community and others from one unit to another; staff said there had been visits and discussions between staff, residents and their relatives prior to any move. Information about resident’s needs had been included in their individual plan and any risks to their safety had been assessed. Registered nurses provided care for those residents who needed specialised nursing care. There was evidence of assessments from social services, physiotherapy and speech and language therapists that ensured all aspects of care were considered. Lisieux Hall DS0000025567.V323075.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Details about resident’s needs and preferences were included in their individual plan and residents were able to make decisions about their lives. Risks to resident’s health and safety had generally been assessed however action to be taken by staff to minimize or eliminate the risks had not always been recorded. EVIDENCE: Three individual plans were looked at. These were selected at random. All residents had individual plans that generally described the support and care needed to meet their needs. The plans included information about care, rehabilitation, communication and specialist aids and adaptations. There was detailed information about resident’s likes and dislikes that would help staff to meet their needs. Any restrictions on choice had been identified and assessed and risk assessments were in place to ensure the safety and well being of the Lisieux Hall DS0000025567.V323075.R01.S.doc Version 5.2 Page 11 individual. However two of the residents had been identified as a high risk of developing pressure sores and whilst it was clear that specialist equipment had been provided there were no records to show what action was being taken to reduce or eliminate the risks. Also one resident who was having regular dressings applied did not have clear instructions detailed in a wound care plan to ensure consistency of care. Residents weights had not always been monitored although equipment had been provided to monitor this health need. The registered manager had completed six monthly audits of all individual plans to ensure staff were following policies and procedures and meeting residents needs. Areas requiring action had been agreed with staff on each unit and there was evidence that generally staff had responded and had improved the standard of the records. There was evidence that residents, their representatives and appropriate others had been involved in decisions about care and one visitor said she was consulted about care and ‘kept informed of important matters’. The plans were not available in other formats that the resident may understand better. Each resident had a key worker who they could spend one to one time with both inside and outside the home. One to one time was recorded on the staffing rota to ensure staff were free to spend uninterrupted time with the resident. Staff said that advocates to act on resident’s behalf would be approached if needed and had been accessed in the past. Lisieux Hall DS0000025567.V323075.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. Residents were supported to take part in a range of age, peer and culturally appropriate activities both inside the home and in the local community and were able to maintain appropriate relationships with family and friends. The menus offered a choice of suitable meals that met resident’s individual needs and preferences. EVIDENCE: Activities were usually agreed with individual residents, taking into account their choices and preferences, then recorded on a weekly activity plan. The activity plans showed that residents took part in a wide range of fulfilling activities that met their individual needs and expectations. Staff had obtained lots of information about resident’s preferences, likes and dislikes and these were taken into consideration when planning suitable activities. Some activities were one to one and others were in small groups of people with similar Lisieux Hall DS0000025567.V323075.R01.S.doc Version 5.2 Page 13 interests. Support for residents both inside and outside of the home was flexibly provided and was recognised by staff as an important part of their role. Two residents were going to the football match with their key workers and the routines of the unit were flexible enough to accommodate this. One resident said he attended work and college each week and enjoyed this, another worked on a nearby farm and one of the ladies had joined a local walking group. There was an activity centre on site and residents were able to make use of this to help them to plan their activities. Residents were seen participating in various activities around the home and were able to access all areas safely. One resident frequently rode his bicycle around the grounds of the home. Residents who wished could visit the main administration building for a chat and a drink and to meet visitors. Holidays were arranged for small groups of residents with similar interests or who had developed special friendships. The home had three adapted vehicles to ensure residents could easily get out and about. One relative said management and staff made them feel welcome when they visited. Staff said visitors would be welcome to visit at any time and would be given encouragement and support to become involved in the activities of the home. Residents did not have locks to their doors and risk assessments suggested they would not be able to manage their own keys. Locks were provided on bathroom doors to ensure residents privacy and the home provided both male and female staff to support choice and dignity issues. Some units had a separate quiet lounge for residents to spend some time on their own if they preferred, others were seen in lounges or in their rooms. Each unit had their own menus; meals were cooked in the unit kitchens by staff with some assistance from residents if able. Staff said menus were planned each week following discussion with residents and taking into consideration their likes and dislikes. Meals were varied and nutritious although the menus did not show a choice. Staff said they would provide an alternative if necessary but generally residents were involved in planning and enjoyed the meals. The registered manager said if an alternative meal had been provided this would be recorded on individual sheets although these were not seen during the inspection. Mealtimes were relaxed and flexible to suit resident’s activities and those who needed help at mealtimes were given sensitive support. A full and completed record of food served should be maintained to show that resident’s received a varied and nutritious diet. Lisieux Hall DS0000025567.V323075.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Resident’s healthcare needs were identified and met and they were protected by the homes policies and procedures for dealing with medication. EVIDENCE: Individual plans detailed residents preferences about how they would like to be looked after and supported. Staff were aware of the resident’s needs and responded appropriately maintaining residents privacy and dignity and independence. Routines were flexible around meeting resident’s needs and choices. There were a range of technical aids and equipment around the home and much had been designed to meet individual needs, safety and comfort. The home ensured that care was consistent by providing a key worker, including information in the individual plan about routines and preferences and supporting contact with friends, advocates and relatives outside the home. Lisieux Hall DS0000025567.V323075.R01.S.doc Version 5.2 Page 15 Access to local healthcare advice and support was seen on the individual plan detailed in a separate healthcare plan. Resident’s health was monitored and a record of any visits by health care professionals was recorded. The medication policies and procedures were not available on any of the units and should be provided as a reference for all staff that manage medication. There were no residents who were able to self-administer and this had been risk assessed and consent for staff to manage resident’s medication had been obtained and included in the plan. The home needed to see the prescriptions prior to dispensing to reduce any errors and identify any alterations. Medications that were prescribed ‘when needed’ were supported by written protocols however these must be stored with the residents chart for staff to use as a safe reference. All staff received drug administration training and assessments to ensure they had the appropriate skills. Records were clear and accurate and showed that medication was safely managed. Lisieux Hall DS0000025567.V323075.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents were protected form abuse, neglect and self-harm by staff awareness and the homes policies and procedures. EVIDENCE: The home had a clear complaints procedure that ensured that all complaints would be dealt with sensitively and appropriately. The procedure was included in the service user guide and given to residents and their representatives. The home had clear adult protection procedures that ensured any suspicion or allegation of abuse would be responded to appropriately. Records showed that all staff had received ongoing adult abuse training and staff confirmed this was mandatory. All staff had Protection of Vulnerable Adults and Criminal Records Bureau checks completed to ensure they were suitable to work with adults. Information supplied before the inspection indicated the home had procedures for managing aggression and managing residents finances that would ensure their safety and well-being. Records of finances were checked at random. Records were clear and resident’s finances were secure and safe. Regular audits were completed on each unit to ensure staff were following policies and procedures and acting in the best interest of the residents in their care. Lisieux Hall DS0000025567.V323075.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents were provided with a clean, safe and comfortable environment that met their collective and individual needs. EVIDENCE: Lisieux Hall is located in extensive and attractive grounds that were safe and accessible for residents, staff and visitors. Residents lived in separate units or homes and each unit had its own facilities and designated staff team. During the inspection five units were occupied and visited; the sixth unit was being completely refurbished and residents from one of the other units would move in. All units were single storey buildings and people in wheelchairs could access all areas. All units were bright, comfortable, clean and free from odours and the environment reflected the needs and choices of the residents who lived there. Lisieux Hall DS0000025567.V323075.R01.S.doc Version 5.2 Page 18 Bedrooms were comfortable and personalised and suited the needs and lifestyles of the individuals. There were no locks on bedroom doors but risk assessments were seen to support this. Bathrooms and toilets were fitted with suitable locking devices to ensure resident’s privacy whilst being supported by staff. Communal areas were bright and comfortably furnished. Various aids and equipment were provided to meet the assessed needs of individual residents and there was evidence that specialists had been consulted to ensure residents had been provided with appropriate support and equipment. Each unit had a plan for maintenance and renewals and a maintenance team was available for this. The units were well-maintained and showed residents needs and choices had been taken into consideration. There were a small number of areas that were in need of attention including broken drawers and weigh scales; staff said these had been reported to the maintenance department but there had been some delay regarding action being taken. This was discussed with the registered manager who was already aware of the problem. Lisieux Hall DS0000025567.V323075.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. Resident’s needs were met by an established team of qualified and competent staff who were well supported and supervised in all aspects of their work. The home followed a robust recruitment procedure that ensured residents were protected from unsuitable people. EVIDENCE: From records and discussions with staff it was clear that more than half of the staff had an appropriate qualification in care and that the home provided a range of training to ensure staff had the skills and experience needed to meet the needs of the residents in the home. All staff received annual reviews and were regularly supervised to identify any need for extra training and support. One resident said staff were ‘nice people’ and he was ‘looked after’. The rotas were clear and staffing was set for each unit. Staff said there were sufficient staff numbers to meet the needs of the residents and allowed time for key workers to spend with their residents. All staff spoken to had worked Lisieux Hall DS0000025567.V323075.R01.S.doc Version 5.2 Page 20 at the home for two years at least and one member of staff said ‘this provided continuity of care for the residents’. One member of staff said ‘ I love working here’. There had been no new staff since the last inspection. Two staff recruitment files were looked at and both contained the appropriate checks that ensured the protection of residents. There was no evidence that residents had been involved in the recruitment process although this could be considered when any new staff were recruited. A record of interview had been maintained that ensured a fair selection process. All staff had training records and were sent an updated version each year indicating what they had attended and needed to attend to maintain their skills and knowledge. Records showed that staff were appropriately qualified and that the home provided staff with a range of training that ensured they were well trained and competent to meet the diverse needs of individuals in their care. The home had a training department in the grounds of the home. One member of staff said ‘the training is excellent’ another said ‘we are given the training we need to do the job properly’. All staff should receive equal opportunities, disability equality, race equality and anti racism training to ensure all aspects of resident’s rights and best interest are protected. Lisieux Hall DS0000025567.V323075.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents generally benefited from a well run home that respected their views and opinions and protected them from harm although some aspects of health and safety needed to be improved. EVIDENCE: Lisa Fitzsimmons is the recently registered manager for the home. Lisa is a registered general nurse and is currently coming to the end of a degree course in Learning Disability Studies, which she undertook to enhance her knowledge in working with people with this disability. Lisa intends to undertake a recognised management qualification to assist her with her role on completion Lisieux Hall DS0000025567.V323075.R01.S.doc Version 5.2 Page 22 of the degree course. The training records support that Lisa has updated her skills and knowledge. Staff made positive comments about the contribution that Lisa made to the management team and said she was ‘very approachable’ and ‘gets things done’. There were quality assurance systems in place to monitor whether the home was meeting the aims and objectives and whether it was meeting resident’s and relatives needs and expectations. Policies and procedures were regularly reviewed and updated in light of changes to legislation and residents needs. Records supplied prior to inspection showed that the registered manager generally protected the health safety and welfare of staff, residents and visitors to the home. Staff had attended regular fire safety training and moving and handling training although it was noted on two units that records of fire drills were not up to date, assessments of risks to residents had not been updated on one unit and the electrical wiring certificates were out of date on some of the units and this could put residents at risk. The registered manager was made aware of this. Lisieux Hall DS0000025567.V323075.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 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 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 3 32 4 33 3 34 3 35 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 4 15 4 16 4 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 2 X Lisieux Hall DS0000025567.V323075.R01.S.doc Version 5.2 Page 24 N/A Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement Timescale for action 19/03/07 2. YA42 23 3. YA42 23 The individual plans must clearly indicate what action staff must take to ensure resident’s healthcare needs are met with particular reference to pressure risk assessment and wound care. Records must be maintained on 19/03/07 each unit to support that regular testing of fire systems and regular fire drills and practices have taken place. The registered manager must 01/03/07 ensure the electrical systems and wiring are regularly tested and maintained on all units. Certificates to support up to date electrical wiring tests must be forwarded to the Commission for Social Care Inspection. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Lisieux Hall DS0000025567.V323075.R01.S.doc Version 5.2 Page 25 1. 2. 3. YA6 YA17 YA20 4. 5. 6. YA24 YA37 YA42 Consideration should be given to providing individual plans in other formats A record of meals served should be maintained. Medication policies and procedures need to be available on all units Prescriptions need to be seen prior to dispensing to identify any errors. The PRN protocols need to be stored with the resident’s medication administration record. Repairs to resident’s furnishings and fittings should be done promptly. The registered manager needs to obtain a management qualification at level 4 NVQ. The registered manager should ensure risk assessments show evidence of review on all units. Lisieux Hall DS0000025567.V323075.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Unit 1 Tustin Court Port Way Preston Lancashire PR2 2YQ 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 Lisieux Hall DS0000025567.V323075.R01.S.doc Version 5.2 Page 27 - 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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