Inspection on 26/05/06 for Lisieux House

This inspection was carried out on 26th May 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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lisieux House 07/08/07

Lisieux House 09/01/06

Lisieux House 10/10/05

Lisieux House 18/03/05

Lisieux House 08/09/04

Lisieux House 09/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Lisieux House 50 Birmingham Road Sutton Coldfield West Midlands B72 1QP Lead Inspector Gerard Hammond Unannounced Inspection 26th May & 1st June 2006 09:30 Lisieux House DS0000016994.V296462.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 House DS0000016994.V296462.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 House DS0000016994.V296462.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lisieux House Address 50 Birmingham Road Sutton Coldfield West Midlands B72 1QP 0121 355 1474 0121 355 1474 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) Lisieux Trust Catherine Moran Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Lisieux House DS0000016994.V296462.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 12 residents with a learning disability under 65 years. The home can continue to accommodate one named service user over 65 years with a learning disability. The details regarding how the specific care and social needs of the person over 65 years will be included within the service users plan and kept under periodic review to ensure their needs continue to be met. 9th January 2006 Date of last inspection Brief Description of the Service: Lisieux House provides accommodation, care and support for twelve adults with learning disabilities. It is run by the Lisieux Trust, a well-established local organisation providing a range of services for learning disabled people. The premises include the original house, which accommodates eight people, and a separate bungalow (on the same site) providing a further four places. The main house can be accessed on foot from Birmingham Road on the edge of Sutton Coldfield town centre. Vehicular access is off College Hill to the rear of the property, and there is parking space for five or six cars between the two buildings. The main house is a large detached property. On the ground floor is a large kitchen with dining space, a separate dining room, hallway and a spacious, comfortable lounge. The office and staff sleep-in room, the laundry, shower room and toilet are also situated on this floor. On the first floor are six single bedrooms, a bathroom with w.c., separate w.c., and further bathroom with shower over the bath. On the second floor there are two more single bedrooms, another bathroom with shower over and w.c. The purpose-built bungalow (“Bartres”) has four single bedrooms (two of which have en-suite facilities), a kitchen / diner, laundry, bathroom, separate w.c., and an office. Both houses have their own private gardens, which include patio and seating areas, flowerbeds and lawns. Outbuildings between the two houses accommodate storage space and an activity room. The house and the bungalow are both furnished and fitted to a very high standard, and both gardens provide attractive outdoor spaces. The home is within easy walking distance of a full range of social and leisure amenities in Sutton town centre, and is well served by public transport links. Lisieux House DS0000016994.V296462.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. It should be noted that Lisieux House has now been inspected three times in a relatively short period. This is entirely due to workload management issues within CSCI and does not relate to practice within the home. This inspection included the gathering of information from a range of sources including previous inspection reports, the service history and other documents held by CSCI. Two visits were made to the home. On the first, the Inspector examined records including personal files, care plans, and safety records. The senior staff member on duty was interviewed formally, and two other members of staff were seen informally. A number of residents were away on holiday, but the inspector met all of the people who were at home. On the second visit, the Inspector met with the Registered Manager, who was away on leave on the first occasion. Thanks are due to the residents and staff for their support and help throughout the inspection. What the service does well: People at Lisieux House enjoy the benefit of living in accommodation that is welcoming, comfortable and homely. The service provides a home environment of a very high standard. Staff support residents to be as independent as they are able. People’s rights are respected, and they are actively encouraged to recognise their personal responsibilities. Residents are able to pursue a wide range of valued activities. They enjoy good access to local amenities for leisure and recreation, and enabled to be a part of their local community. People are encouraged and supported to maintain relationships with families, friends and loved ones. Residents receive a good level of basic personal care. They have access to a diet that is balanced and nutritious. They are supported to access primary and specialist healthcare, according to their needs. The service seeks to engage with the people who use it by actively seeking their views. People’s right to complain is actively supported. Residents benefit from the support of a qualified team and a Manager who is committed to developing and improving the service. Lisieux House DS0000016994.V296462.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Care plans need further development so that they include precise detail about how support should be given, in accordance with assessed needs and individual preferences. It is anticipated that this will be addressed as individual plans are reviewed. Plans should also include individuals’ goals, which should have outcomes that can be measured. These should be looked at when the plan is reviewed, and decisions made about what is working and what might need to be changed. It should be acknowledged that work to improve and develop care planning is under way and ongoing. Risk assessments should be directly linked to the care plan(s) to which they relate: indexing and cross-referencing could support this process. Identified training shortfalls, notably in adult management and fire safety should be addressed. protection, medication Some aspects of maintaining safety records needs to be more thorough. Lisieux House DS0000016994.V296462.R01.S.doc Version 5.2 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. Lisieux House DS0000016994.V296462.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 House DS0000016994.V296462.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The quality of outcomes in this area is good. Residents’ needs and aspirations are assessed appropriately. EVIDENCE: Standards 1-5 were all assessed at the last inspection, and met in full. There have been no new admissions since that date. Sample checking of personal records showed that residents have appropriate assessments of strengths and support needs in place, and that these are being updated and reviewed as necessary. There is evidence that a considerable amount of work is currently going on to try and improve the way in which this information is recorded and presented, so as to support the development of care management practice (see Standard 6 below also), and this should be commended. Lisieux House DS0000016994.V296462.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 The quality of outcomes in this area is good. People’s assessed needs are generally reflected in their care plans. Work to develop these should continue to extend the inclusion of their personal goals. Residents are supported to make decisions about their lives and are consulted appropriately. Staff encourage them to take part in all aspects of life in the home in accordance with their individual capabilities. People are encouraged to take risks in a responsible manner, so as to enhance their personal independence, but risk assessments need further development. EVIDENCE: It was noted in the last inspection report that care plans were in need of further development in some areas, while recognising that personal records contained good quality information about residents’ support needs and how to meet them. Sample checking of individuals’ files provided evidence that this is a work in progress, and that clear efforts are being made to develop plans appropriately. Lisieux House DS0000016994.V296462.R01.S.doc Version 5.2 Page 11 Work already done should be built upon. In particular, some aspects of individuals’ plans need to be more detailed. For example, one plan identified a resident’s need for support with cooking. It is suggested that the plan should indicate how this person might be supported / taught to cook a new dish. Does this person understand weights and measures, can he / she follow a recipe, does he / she understand the need for kitchen hygiene? Perhaps this person’s involvement in cooking a new dish has to be confined to helping mix ingredients “hand over hand” or just enjoy the sensations associated with preparing food (such as smell and taste), because of the level of disability. The plan should be expanded so that these things are made explicit. It was also noted that sometimes care plan information appears to be at odds with statements of need. In one instance, someone’s plan showed “capable of choosing the right clothes for the occasion or weather”, but the assessment showed “I need to be shown first”. It is important that care plans arise directly from individuals’ assessed needs, and that information is consistent. The intended outcome for Standard 6 is that “service users know their assessed and changing needs and personal goals are reflected in their individual plan”. Goal setting is an essential component of the care planning process. It is important that goals set should have outcomes that can be measured. These should be evaluated when the plan is reviewed and decisions made about what is working and what needs to be changed. Plans should be reviewed at least every six months, with written records kept indicating the names of those taking part and how decisions are made. There is evidence that plans are being reviewed and also of efforts being made to set goals. A system is in place for key workers to evaluate plans on a monthly basis, and this provides opportunities for setting goals. This is another example of good practice, and should be acknowledged. It is suggested that this might be further developed by focussing on ways of making the goals set measurable, setting time limits and indicating specifically who is responsible for doing what. Good practice already in place needs to be extended “across the board”. It was also noted that work is already going on to further develop the use of person centred approaches, in keeping with the aspirations of the Government White Paper “Valuing People”. This too should be commended, encouraged and built upon. As indicated at the time of the last inspection, risk assessments continue to be in need of further work. Conversations with the Manager and with staff indicate a positive attitude to supporting residents to take risks responsibly, and that this is seen in the context of providing opportunities for learning and personal growth. It was noted that one person has experienced recent difficulties as a result of accessing the Internet. It is clear from conversations held that this matter has been considered carefully and appropriate action taken to address the identified problems. However, this was not reflected in the personal records, and an appropriate written risk assessment should be put in place. Lisieux House DS0000016994.V296462.R01.S.doc Version 5.2 Page 12 Risk assessments should be directly cross-referenced to the care plan(s) to which they relate, and vice versa. It is recommended that care plans and risk assessments are numbered and indexed clearly, so as to make it easy to “track” from one to the other. The control measures arising from the completion of the risk assessment process should be used to inform the care plan(s) appropriately. During the course of the visit, members of the care team were directly observed offering people choices about what they wanted to do, supporting them to make decisions appropriately, and encouraging them to do things for themselves, so as to promote personal independence. People living in the house have regular meetings to discuss issues of interest. A person who is independent of the staff team facilitates this. This practice supports consultation with the residents, in addition to one to one contact. Lisieux House DS0000016994.V296462.R01.S.doc Version 5.2 Page 13 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, 14, 15, 16, 17 The quality of outcomes in this area is good. Residents enjoy opportunities to take part in valued activities and to be part of the local community. People are appropriately supported to maintain the relationships important to them. Residents’ rights are respected and they are encouraged to accept their responsibilities appropriately. People enjoy their food and have access to a balanced diet. EVIDENCE: On the day of the inspection, four of the residents in the main house were away on holiday. Another holiday is planned later in July. People living at Lisieux House enjoy a wide range of opportunities for social, education and leisure activities. Several attend local centres and colleges for structured activities during the day. The home is well placed for accessing local amenities Lisieux House DS0000016994.V296462.R01.S.doc Version 5.2 Page 14 in Sutton Coldfield, and residents make full use of these, in groups and individually, with support as required. Activity records for the previous month also indicated that people had been to a number of local clubs and to the pub, shopping, walks in the park, for meals out, attended a conference, and saw a production of “Guys and Dolls” at the town hall. It is recommended that recording of activities is expanded, and that clearer links are established between what people do and their assessed needs and care plans. Used positively, this could provide good opportunities to develop people’s personal goals. A good example of this actually happening was observed on one person’s record. In creating a person centred plan, this person indicated that she dreamed about going on a cruise. This was noted, and she was supported to achieve her goal. Residents also have “training days”, when staff support them to learn, develop or maintain skills by taking responsibility for things around the house. This might include maintaining their own rooms, doing domestic tasks around the house, and preparing and cooking food. People living in the house are supported and encouraged to keep in touch with families and loved ones in a number of ways. Some regularly spend time at their relatives’ homes, others have visits at Lisieux House and keep in touch by telephone, according to the wishes of those involved. Conversations with staff indicated that people’s rights are recognised and respected, but that they are also encouraged to accept the responsibilities that naturally accompany this. Supporting people to be as independent as their personal abilities permit provides good evidence of this principle being put into practice, and this was directly observed throughout the visit. Residents actively participate in shopping for food and making choices about meals. Food stocks were examined: available supplies were plentiful and included fresh produce. Records provided additional evidence that people enjoy a diet that is sufficiently varied, balanced and nutritious. However, records indicating “packed lunch” or “sandwiches” should say what was actually in them, and it was noted that there were some gaps in recording. Lisieux House DS0000016994.V296462.R01.S.doc Version 5.2 Page 15 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, 19, 20 The quality of outcomes in this area is good, though some issues need to be addressed. Residents are generally supported in accordance with their assessed needs, but care plans need development to include more detail about personal preferences. The healthcare needs of people living in the house are generally well met, but Health Action Plans should be completed to show how specific issues are being dealt with. General practice in the storage, handling and administration of medication is satisfactory, but there are shortfalls in training that need to be addressed. EVIDENCE: As indicated earlier in this report, care plans are in need of some development, so that guidance is clear as to exactly how support should be given, in accordance with individual preferences. One individual’s statement of need indicated that she required prompts to wash and attend to aspects of personal hygiene, but this was not reflected adequately in her care plan. However, work currently underway to extend the use of person centred approaches should address these issues as plans are developed. It is important that the detailed Lisieux House DS0000016994.V296462.R01.S.doc Version 5.2 Page 16 knowledge that members of the care team have about the people they care for is appropriately recorded in their plans, and in particular their individual personal preferences. Residents’ attire and personal grooming provided clear evidence that they receive a good standard of basic personal care. Staff were directly observed giving support to residents, and interactions were seen to be warm and friendly and appropriately respectful. Both staff and residents appear to be at ease in each other’s company Personal files provided evidence that people living in the house are supported to access primary health care and are referred for to members of the multidisciplinary team for specialist support as required. It was noted that work has been started to introduce Health Action Plans, but that this is at an early stage. Information on individual records is in the nature of a preliminary assessment. This now needs to be built upon and clear action plans developed to address specific individual health needs. It may be that support for this should be sought from the local Community Nurse (LD) Team. One person’s record indicated that high blood pressure is a problem and also indicated specific medical conditions, but it was not clear from the record what is actually being done to address these. This person’s record also showed that she self medicates: a risk assessment was in place, but this now needs to be reviewed. The Medication Administration Record was examined. There were no gaps in recording and the record included copies of prescriptions and photographs of each resident, as required at the time of the last inspection. The Manager has written to the GP with regard to completing protocols for PRN (“as required”) medication and homely remedies. This now needs to be followed up. Information provided by the Manager on staff training indicates that several staff members have yet to receive training in medication management, and this must now be rectified. The Accident Book was also seen. It is recommended that each report counterfoil be marked with the initials of the person to whom it relates and the date, so as to facilitate tracking. Also, that a prominent note be placed on the book to remind staff of the requirement to make reports to CSCI under Regulation 37 (Care Homes Regulations 2001). Lisieux House DS0000016994.V296462.R01.S.doc Version 5.2 Page 17 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 quality of outcomes in this area is good. Residents are consulted in a variety of ways in order to find out their views. General practice promotes the protection of residents from abuse, neglect and self-harm, but shortfalls in training among the staff team need to be addressed. EVIDENCE: The complaints book was examined. One issue that arose since the last inspection has been investigated and dealt with appropriately. Some of the people living in the house would be able to make use of the formal complaints process; others would not. The care team and the wider organisation actively seek to ensure that people’ rights to complain are promoted appropriately. This is done in a number of ways. As recorded earlier in this report, efforts are made to consult through independently facilitated residents’ group meetings, and through individual meetings with key workers. There is also a system whereby residents have postcards they can send to alert the organisation to the fact that there is a problem, which can then be followed up independently. One resident spoken to indicated that he knew that he could talk to staff if he had a problem, and would be comfortable to do so. The Adult Protection Policy could not be located on the day of the Inspection visit, but a copy of the local multi-agency guidelines has now been obtained, as previously required. It is recommended that the Adult Protection Policy is directly cross-referenced to Local Multi-Agency Guidelines on the Protection of Vulnerable Adults from Abuse, and that the policy explicitly states that no Lisieux House DS0000016994.V296462.R01.S.doc Version 5.2 Page 18 investigation must commence until a Police decision is given. Information relating to staff training indicated that five of the current staff team have not received Adult Protection Training, and a further two people are now due for a “refresher”. Records relating to residents’ personal money was sample checked. The amounts held tallied with the account, and receipts were available to support records of purchases made. Financial risk assessments were in place on sampled files, in accordance with requirements made at the last inspection. Lisieux House DS0000016994.V296462.R01.S.doc Version 5.2 Page 19 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, 30 The quality of outcomes in this area is excellent. Residents enjoy living in accommodation that is homely, comfortable and welcoming. The Home is clean, tidy and maintained to a high standard. EVIDENCE: A tour of the main house and the bungalow was undertaken. As indicated in previous inspection reports, the standards of furnishing and decoration are very high. Residents at Lisieux House clearly enjoy their home, which is a comfortable and welcoming place. People at home on the day of the inspection were happy and proud to show their rooms. These are individually styled, with personal effects and possessions very much in evidence. Communal spaces, including the gardens, are attractive places to be. The home is kept clean and tidy, and good standards of hygiene maintained throughout. A requirement to complete a plaster repair around a socket in the kitchen remains outstanding. However, this was said to be temporarily “on hold” while decisions were made about the location of a new fridge / freezer in this area in the near future. The Manager indicated that the repair would be dealt with when installation takes place shortly. Lisieux House DS0000016994.V296462.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 The quality of outcomes in this area is good. Residents are supported by an appropriately qualified and competent staff team. Recruitment policy and practice promotes the protection of people living in the house. There are some shortfalls in meeting the care team’s overall training requirements. Improvements have been made to arrangements for formal supervision of staff, and these should continue. EVIDENCE: A training skills matrix and additional information provided by the Manager indicates that over 50 of the care team are qualified to the appropriate NVQ level, as required. Recruitment is dealt with from a central point within the organisation. Sample checking of staff files provided evidence of an appropriate process, and necessary documentation was in place on files, as required. Lisieux House DS0000016994.V296462.R01.S.doc Version 5.2 Page 21 As recorded earlier in this report, the training skills matrix provided by the Manager indicates that there are a number of gaps. A training and development plan is required for each member of staff, showing (in addition to information already provided on the matrix) when outstanding training is scheduled, and who is to deliver it. In view of the assessed needs of a number of the people living at Lisieux House, it is recommended that all staff receive specific training in supporting people with Autistic Spectrum Disorders. A requirement was made at the time of the last inspection that all staff receive formal supervision at least six times a year. This has not yet achieved, but action has been taken to address this issue and there are improvements. It is anticipated that this standard will be met in the future if current trends continue. must been clear near Lisieux House DS0000016994.V296462.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42 The quality of outcomes in this area is good. Residents benefit from living in a home that is generally well run, and from the open and inclusive management approach. Clear efforts are made to ensure that residents’ views are sought: how these are used to underpin review and development of the service should be reported upon. General practice promotes the health, safety and welfare of people living in the house, but some aspects of recording need to be improved upon. EVIDENCE: The Registered Manager is appropriately qualified, and experienced in supporting people with learning disabilities. Members of staff indicated that she is approachable and direct observations confirmed that she has a good rapport with the care team and operates an open and inclusive style of management. Lisieux House DS0000016994.V296462.R01.S.doc Version 5.2 Page 23 She is not afraid to delegate appropriately and sees this as providing opportunities for staff growth and development. Arrangements for consulting residents on a day-to-day basis have been recorded earlier in this report. Formal systems for monitoring and quality assurance are in place within the organisation. Monthly visits on behalf of the Registered Provider have generally been carried out and reports submitted as required. A report should be compiled of the outcome of quality and assurance activity and made available to all interested parties. Sample checks of safety records were carried out. The Landlord’s Gas Safety Certificate and the electrical hard wiring certificate were both in date. The certificate for Portable Appliance Testing was not available. A copy of a current certificate should be submitted to CSCI. Tests of the fire alarm and emergency lighting systems have been carried out, and the systems and fire fighting equipment maintained. The staff training skills matrix indicates that fire safety training for staff is overdue, although one person has completed Fire Marshall training recently. Test records of water temperatures showed some gaps: records of fridge and freezer temperatures were generally complete, but the chest freezer must also be included. Legionella testing of the water supply has been carried out. Packages of food stored in the fridge were appropriately labelled with the date of opening. A requirement to update the fire risk assessment has now been met. Lisieux House DS0000016994.V296462.R01.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 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 3 3 3 X X 2 X Lisieux House DS0000016994.V296462.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 (1) Requirement Timescale for action 31/08/06 2. YA6 15 (1) 3. YA9 13 (4) 4. YA18 12 (3) The Registered Manager should ensure that care plans are developed to include sufficient detail about exactly how support should be given, in accordance with individuals’ assessed needs and preferences. The Registered Manager should 31/08/06 ensure that care plans include individuals’ agreed personal goals, which should have outcomes that can be measured. These should be evaluated when plans are reviewed. Whole plan reviews should take place at least every six months, with written records showing who takes part and how decisions are reached. The Registered Manager should 31/08/06 ensure that risk assessments are clearly linked to the care plan(s) to which they relate. A written risk assessment is required for resident (EM) in respect of internet use. The Registered Manager should 31/08/06 ensure that care plans are developed so as to clearly DS0000016994.V296462.R01.S.doc Version 5.2 Lisieux House Page 26 5. YA19 12 (1-3) 13(1b) 6. YA20 13(2) 7. YA35 18(1c) 8. YA36 18(2) 9. YA42 13 (4c) 10. YA42 13 (4c) 23 (2b) 11. YA42 13 (4c) 12. YA42 13 (4c) indicate individuals’ preferences and accurately reflect their assessed needs. The Registered Manager should ensure that Health Action Plans are developed in relation to all identified health needs for each resident. The Registered Manager must ensure that all staff have received training in the safe handling and administration of medication. The Registered Manager should submit a current training and development plan showing (for each member of staff) gaps in training (including “refreshers”) and indicating when outstanding training is scheduled, and who is to deliver it. The Registered Manager must ensure that staff receive formal supervision at least six times in any twelve-month period (prorata for part time staff). (Part met) The Registered Manager must ensure water outlet temperatures are checked every week, and a complete written record maintained. (Outstanding from 16/01/06) The Registered Manager must ensure that damaged plasterwork around the electrical socket in the kitchen is repaired. The Registered Manager must ensure that a daily written record of fridge and freezer temperatures is maintained, and that this also includes the chest freezer. The Registered Manager must forward a current certificate in respect of Portable Appliance DS0000016994.V296462.R01.S.doc 31/08/06 31/08/06 31/08/06 30/08/06 31/08/06 31/08/06 31/08/06 31/07/08 Lisieux House Version 5.2 Page 27 Testing of electrical equipment to CSCI 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 YA6 YA24 Good Practice Recommendations Person centred approaches should be extended to all people who use the service. The Trust should consider what additional improvements can be made to the premises so that it meets the requirements of the Disability Discrimination Act 1995 Part Three. (Not assessed) It is recommended that the Accident Book be annotated to alert staff to the need to make reports under Regulation 37 (Care Homes Regulations 2001), and that report counterfoils are marked with the initials of the person concerned and the date. The registered manger should ensure vehicle checks are carried out at least monthly. (Not assessed) 3. YA19 4. YA42 Lisieux House DS0000016994.V296462.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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. 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