Inspection on 07/08/07 for Lisieux House

This inspection was carried out on 7th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lisieux House 26/05/06

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 Kerry Coulter Key Unannounced Inspection 7th August 2007 09:00 Lisieux House DS0000016994.V342089.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.V342089.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.V342089.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 F/P 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.V342089.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. 26th May 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, shower room 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. The Manager said the current range of fees is £548.20 per week. Copies of previous CSCI inspection reports are on display in the home for people who wish to read them. Lisieux House DS0000016994.V342089.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit was carried out over eight and a half hours, the home did not know we were coming. This was the homes key inspection for the inspection year 2007 to 2008. An ‘expert by experience’ took part in part of the visit. An ‘expert by experience’ is a person who, because of their shared experience of using services and / or ways of communicating, visits a service with an inspector to help them get a picture of what is like to live there. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home and a questionnaire about the home (AQAA). People who live in the home were case tracked this involves establishing individuals experience of living in the care home by meeting or observing them, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking people’s care helps us understand the experiences of people who use the service. Most people who live at the home were spoken to but one person was away on holiday at the time of the visit. CSCI survey forms were received from three people who live at the home and three relatives. Their comments are included in the report. What the service does well: People at Lisieux House enjoy the benefit of living in accommodation that is welcoming, comfortable and homely. Bedrooms are decorated in the way that each person chooses and they contain many personal items. People 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. The staff of Lisieux house provides positive support and encourage people to be as independent as they can. Staff make sure that people eat, drink and do the things that they like. Lisieux House DS0000016994.V342089.R01.S.doc Version 5.2 Page 6 People are encouraged and supported to maintain relationships with families and friends. The views of the people who live there and their families had been asked to make sure the home is running in the way they want it to. 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. Food records must be fully maintained so that staff can make sure that people’s dietary needs are being met. More detailed information is needed about people’s health needs in their care plans to ensure they receive the support they need to stay healthy. The provider’s representative needs to visit the home more often to ensure it continues to be well run. Lisieux House DS0000016994.V342089.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. The summary of this inspection report can be made available in other formats on request. Lisieux House DS0000016994.V342089.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.V342089.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): 1, 2, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have the information they need to make a choice about whether or not the home can meet their needs. Their needs are assessed before they move in and they have an opportunity to visit to help them make a choice about whether or not they want to live there. EVIDENCE: The statement of purpose of the home was dated June 2005. This included the relevant and required information so that it was clear what the home provides. It is recommended that this document is reviewed annually to ensure all the information is up to date. It is good that there is a DVD available about the home, this enables people who are thinking of moving to the home to see what it is like. Since the last inspection one person had moved into the home. Before they moved in an assessment was completed of their needs to ensure that the home is able to meet these and support the person to achieve their goals. Before they moved into the home visits were planned so they could get to know the other people living there and the staff and to help make a decision as to whether or not they wanted to live there. Lisieux House DS0000016994.V342089.R01.S.doc Version 5.2 Page 10 People who live at the home are provided with a ‘licence to occupy’ agreement that tells them about the terms and conditions of their stay to include the fees. Lisieux House DS0000016994.V342089.R01.S.doc Version 5.2 Page 11 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, 8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place so that staff have most of the information they need to support individuals to meet their needs and enable them to make choices about their day- to – day lives. The people living in the home are supported to take risks as part of a risk assessment framework so encouraging their independence whilst maintaining their safety. EVIDENCE: The care records for five people were looked at in full or part. Each person had a care plan. As identified at previous inspections there is still some work to do to develop the plans so that they are fully comprehensive and detail individual needs and how they are going to be met. For example, for one person their plan said they used some Makaton signs but did not detail the signs they knew. Another persons file indicated they needed help with drying their hair and support with feminine hygiene but their assessment and care plan then said they see to their own personal care. Whilst all the care plans had been reviewed in the last six months some of the information was not up to date. Lisieux House DS0000016994.V342089.R01.S.doc Version 5.2 Page 12 The plan for one person said they worked at a charity shop but they had stopped doing this in June. People’s goals are included in their plan, this is titled ‘dream path’. Some people wanted to do things such as go to college, watch a rugby match, go to a concert or have their bedroom decorated. It was good that people had been supported to achieve their dreams. One person spoken with understood what was in their care plan but they did not have their own copy. It would be a good idea if people were asked if they wanted their own copy in a suitable format. People meet with their key worker to discuss any problems they have or changes to their care plan For one person the records of these sessions showed they did not like living with one person who they shared their home with. It was not clear if anything was being done about this. People are fully supported to make decisions about their lives. It is good that regular care reviews are held, records sampled showed that the person is fully involved in their review. 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. Three people spoken with confirmed they had a choice about what time they go to bed. 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 people at the home, in addition to one to one contact. The Manager said people are involved in the recruitment of new staff, two usually attend the recruitment day and take part in the role play, and their views are considered as well as the Managers. The Manager said that the Lisieux Trust wants people who live at the home to be able to influence policy decisions. To facilitate this they are going to be doing elections for people to sit on a board, this will have an independent chair and meet twice yearly. Conversations with the Manager indicate a positive attitude to supporting people to take risks responsibly, and that this is seen in the context of providing opportunities for learning and personal growth. Risk assessments had been completed for areas such as road safety, money, self medication, bathing, fire evacuation, falls and making drinks. In June 2006 the CSCI was notified that one person had choked on some food and needed support from staff. Sampling of this persons file showed a risk assessment had since been completed. Lisieux House DS0000016994.V342089.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at the home enjoy opportunities to take part in valued activities and to be part of the local community. People who live at the home enjoy their food. EVIDENCE: 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 in Sutton Coldfield, and people make full use of these, in groups and individually, with support as required. Records show that people regularly take part in activities such as cinema, church, shopping and clubs. People have also done activities such as going to concerts, football matches, sea life centre and Cadbury World as identified in their ‘dream paths’. People who want to, go on holiday. One person was in Ireland at the time of the inspection, others had already been to Breen. It was good to hear that there were two different holidays, a quiet one and a livelier one for different Lisieux House DS0000016994.V342089.R01.S.doc Version 5.2 Page 14 interests. One person is going to Spain soon with friends. The Manager said that one person had been to Romania with the ‘Special Olympics’ as an overseas ‘advocate’. Some people at the home have jobs, either voluntary or paid. One person was on her way to work on the morning of the visit, she said she worked at Mencap. Another person said she liked animals so worked at a place where they had donkeys. The Manager said it was one persons 80th birthday soon, they are organising a 40’s and 50’s themed event and everyone will be dressing up. People 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. One relative commented they are ‘encouraged to visit’. One person who lives at the home said they were happy here and does not want to move. Another said they have their own key to their bedroom and get to open their own post. One person said ‘this is a good home’. Menus were varied and were appropriate to the cultural background of the people living there. People living at the home said ‘food is nice’, ‘staff do not give me food I don’t like’. Staff said they have a meeting before food shopping is done so that people can say what they want. Food records in the bungalow showed that fruit was part of people’s diet but the records for the main house did not record fruit and sometimes there were gaps in the records. However there was lots of fruit available in the home. People who lived at the home said fruit was available but one person said they did not really eat fruit as they preferred biscuits. Staff need to develop a system to record fruit provided so that they can effectively monitor that people are having a healthy diet. Lisieux House DS0000016994.V342089.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. 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 this service. 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. The medication is generally well managed to protect the people living there from harm and ensure their well being. EVIDENCE: Five people’s files were sampled during the inspection and each file was noted to have, intimate care statements, signed by the person detailing the way they would like to receive personal care. People are able to choose what time they get up in the morning, one staff was observed taking a cup of tea to one person whilst they were still in bed. People’s attire and personal grooming provided clear evidence that they receive a good standard of basic personal care. Records show that people regularly access the hairdressers or barbers. Staff were directly observed giving support to people, and interactions were seen to be warm and friendly and appropriately respectful. Both staff and people who live at the home Lisieux House DS0000016994.V342089.R01.S.doc Version 5.2 Page 16 appear to be at ease in each other’s company. One relative commented ‘individual support is at at a very high standard’. 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. Health assessments had been completed for people but the format of these was quite brief and would benefit from being expanded. For example, for one person it said they needed to go to the opticians regularly but did not say how often this was. 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. Medication administration records were examined. There were no gaps in recording and the record included copies of prescriptions and photographs of each person. Some people are prescribed PRN (as required) medication. Individual protocols were in place stating when, why and what dosage of this medication should be given to the person. Some people at the home look after their own medication, risk assessments were seen to ensure people are safe to do this. The CSCI was notified of a medication error in September 2006. Sampled records showed that appropriate action had been taken to reduce the risk of future errors. Records and discussion with the Manager indicates that all staff who administer medication have been appropriately trained to do so. Lisieux House DS0000016994.V342089.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. 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 this service. Arrangements are in place to ensure that the views of the people living in the home are listened to and generally acted on. Arrangements are in place to ensure that the people living there are protected from abuse, neglect and selfharm. EVIDENCE: The CSCI has not received any complaints about this home in the last twelve months, the Manager said that no complaints had been received by the home. 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. Individual meetings are also held with key workers. There is also a system whereby people have postcards they can send to alert the organisation to the fact that there is a problem, which can then be followed up independently. The AQAA completed by the Manager recorded ‘the staff and residents are listened to and their input is important’. Discussions with people who live at the home during the visit and receipt of surveys shows most people are aware of the complaints procedure but some were not. It was observed that a copy of the complaints procedure was not on display in the bungalow and there was not an accessible procedure on display in the main house. The Manager said there was usually a copy on display and Lisieux House DS0000016994.V342089.R01.S.doc Version 5.2 Page 18 she would ensure it was put back up. Comments from relatives showed they were all aware of the complaints procedure. Records relating to people’s 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. People’s money is checked by staff at each change of shift to ensure the money is correct. Ten of the thirteen staff have received training on the protection of vulnerable adults, the remaining three staff have had basic training as part of their induction. One of the newer staff was spoken with about what they would do if they had suspicions of abuse occurring and their knowledge was adequate. Further training for those staff who need it is provisionally booked for November. Lisieux House DS0000016994.V342089.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People 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 good. People at Lisieux House clearly enjoy their home, which is a comfortable and welcoming place. People said ‘my bedroom is lovely’, ‘ I like my big room’. Another said they liked their bedroom and they had chosen the colour. They also said they were pleased that the upstairs bathroom had been changed to a shower as they preferred showers. People at home on the day of the inspection were happy and proud to show their rooms. Everyone has their own bedroom. Some people who live in the bungalow have en suite bathrooms. Bedrooms had been personalised to individual tastes, ages, cultural backgrounds and interests. Communal spaces, including the gardens, are attractive places to be. The Manager said that a new Lisieux House DS0000016994.V342089.R01.S.doc Version 5.2 Page 20 handrail had been fitted in the garden since the last inspection to assist people who have mobility difficulties. The home is kept clean and tidy, and good standards of hygiene maintained throughout. Lisieux House DS0000016994.V342089.R01.S.doc Version 5.2 Page 21 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 good. This judgement has been made using available evidence including a visit to this service. Arrangements are generally sufficient to ensure that an effective, competent and supervised staff team who can meet individual’s needs support them. The people living there are protected by the home’s recruitment practices. 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 so ensuring that care staff have the skills and knowledge to meet the needs of the people living there. Staff spoken with had good knowledge of the needs of people who lived at the home. One relative commented ‘the staff could do no more’. Sometimes due to staff sickness people have to cancel their activity plans. At the time of the inspection some people were not at colleges due to the summer holidays. The Manager said she usually tried to have extra staff at these times but due to staff sickness there was not always extra staff on duty. One relative commented that ‘more activities need to be organised during the college holidays’, this needs to be considered by the Manager. The Manager needs to Lisieux House DS0000016994.V342089.R01.S.doc Version 5.2 Page 22 make sure that there are enough staff so that people can do the activities they enjoy, when they want to. 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. As stated earlier in this report it is good that people who live at the home are included in the recruitment of new staff. Volunteers are used at the home, for example for chairing meetings with people who live at the home. Records sampled showed that references and a Criminal Record Bureau check are obtained for volunteers so that people are not put at risk by having unsuitable people working with them. The Manager said that when new staff start work in the home they work as an extra staff for three weeks and ‘shadow’ other staff. One new staff said they had been well supported and received lots of training, they also said they enjoyed working at the home. Sampled staff records show that new staff had completed an induction to the home. For new staff who commence work in the future an updated induction is in place that links to ‘Skills for Care’ standards. The staff training records show that staff have had most of the training they need to meet the needs of the people who live at the home. Where there are some gaps in training provisional dates have been set for training. The home currently has thirteen staff all but one staff has done first aid training, eleven staff have done food hygiene, ten have done protection of vulnerable adults, twelve have done manual handling (however no people at the home currently need manual handling). Staff have also been trained to administer medication. The majority of staff have done training in autism and some have done mental health, ageing, dementia and deaf awareness. Records show that staff meetings and supervision are regular so that staff receive the support they need. In addition a recent team building day was held where staff went to Lazer Quest. Lisieux House DS0000016994.V342089.R01.S.doc Version 5.2 Page 23 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, 38, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements ensure that the people living there benefit from a well run home and can be confident that their views underpin all self-monitoring, review and development by the home. 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. Arrangements for consulting with people on a day-to-day basis have been recorded earlier in this report. Records show that in 2006 visits to the home on behalf of the Registered Provider were generally carried out monthly and a report provided. However in 2007 visits have not been so regular and reports from all visits were not available in the home. Lisieux House DS0000016994.V342089.R01.S.doc Version 5.2 Page 24 A quality audit was completed in 2006 using questionnaires for people who live at the home, staff, relatives and professionals. A report of the audit was available that includes actions and responses. Fire records showed that staff had training in fire safety. Staff had regularly tested the fire equipment to make sure it is working. Fire records showed that the last fire drill was in August 2007. The Landlord’s Gas Safety Certificate and the electrical hard wiring certificate were both in date. Certificates were available to show that portable electrical appliances had been checked. Records show that staff do basic checks of the home vehicle monthly to ensure it is in good order. Staff test the water temperatures weekly to make sure they are not too hot or cold. Packages of food stored in the fridge were appropriately labelled with the date of opening. Staff test the fridge and freezer temperatures daily to make sure they are within the limits for safe food storage. Records showed that they were within the safe limits. Lisieux House DS0000016994.V342089.R01.S.doc Version 5.2 Page 25 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 3 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 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 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 4 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 3 2 X X 3 X Lisieux House DS0000016994.V342089.R01.S.doc Version 5.2 Page 26 No 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 YA39 Regulation 26 Requirement The registered provider’s representative must do monthly monitoring visits of the Home when discussions should take place with people living in the home and they inspect the premises so that they can form an opinion about the standard of care provided to people and produce a report on the outcome. Timescale for action 30/09/07 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. Refer to Standard YA6 Good Practice Recommendations 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. People who live at the home should be asked if they would like a copy of their care plan. Ensure action is taken to take into account people’s views DS0000016994.V342089.R01.S.doc Version 5.2 Page 27 2. 3. YA6 YA6 Lisieux House 4. 5. 6. YA17 YA19 YA22 7. YA33 arising from key worker meetings. Food records must be fully maintained so that there is evidence that peoples dietary needs are being met. More detailed information is needed about people’s health needs in their care plans to ensure they receive the support they need to stay healthy. The complaints procedure needs to be on display in both the main house and the bungalow, in a format that people can understand so that people know how to make a complaint. Staffing levels should be increased when people are on holiday from colleges so that there are enough staff on duty for people to do the things they enjoy. Lisieux House DS0000016994.V342089.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: 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 House DS0000016994.V342089.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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