Inspection on 09/01/06 for Lisieux House

This inspection was carried out on 9th January 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 11 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 26/05/06

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 Alison Stone Unannounced Inspection 9th January 2006 09:45 Lisieux House DS0000016994.V275802.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lisieux House DS0000016994.V275802.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lisieux House DS0000016994.V275802.R01.S.doc Version 5.1 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.V275802.R01.S.doc Version 5.1 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. 10th October 2005 Date of last inspection Brief Description of the Service: Lisieux House is an attractive domestic property comprising of three floors and a separate modern bungalow situated on the edge of Sutton Coldfield town centre. Together these properties provide accommodation for eleven adults with a learning disability. The homes are well situated for the local amenities, being close to bus and train routes and Sutton’s leisure and shopping facilities. The main property, Lisieux House has a large lounge and separate dining room, a kitchen/diner, seating in a number of quiet areas and toilets and bathrooms. All bedrooms are of single status. Furniture, fixtures and fittings are of a very high standard. Bartres Bungalow is situated at right angles to the main property and beyond its rear garden. The bungalow currently accommodates four service users in four single rooms, two with en-suites. The communal areas comprise of a lounge, kitchen/diner, a laundry and a well-appointed rear garden. The furniture in this property is also of a very high standard. Situated between the two premises and to the right of the garden of the main house a garage has been converted into an activity room. There is a dedicated parking area situated behind both properties with sufficient space to accommodate five vehicles. Lisieux House DS0000016994.V275802.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a day. It was carried out by one inspector, the inspector spoke with the people who live in the home, the manager and some of the staff. Some records were looked at, including staff records, the records of the people who live in the home, menus and health and safety records. This report is part of two inspections carried out over the last year and for a full picture of the service provided this report should be read in conjunction with the previous report carried out 10 October 2005. The inspector would like to thank the people who live there and the manager and staff for the help and support given during the inspection. What the service does well: What has improved since the last inspection? The manager and staff have worked very hard in a very short period of time to meet nearly all the requirements and recommendations from the last inspection. Lisieux House DS0000016994.V275802.R01.S.doc Version 5.1 Page 6 The rota demonstrated staffing levels have improved since the last inspection, and the manager said that the practice of staff working long hours and backto-back shifts, no longer takes place. The manager said that in nearly all cases, she is able to ensure there are reasonable staffing levels; this is also the case in emergency situations like sickness absence. Staff undertake regular fire tests, and two yearly evacuations. The manager confirmed that where it has been identified people have difficulties evacuating the home; have a risk assessment in place on their individual files. There have been no omissions on the medication administration records since the last inspection. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lisieux House DS0000016994.V275802.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lisieux House DS0000016994.V275802.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 All the standards in this area are met. The service has a completed Service User Guide and Statement of Purpose; this is further supported by a DVD presentation, and is available to new service users. Supporting them, during the introductory visits to be able make an informed decision about what the homes like. The service users are supported with an assessment prior to moving in, this enables service users individual needs and aspirations to be identified. To help service users with the transition of moving into the home, they are fully supported to visit and test-drive the home, prior to moving in. Each service users has an individual contract, ensuring they are fully aware of their terms and conditions. EVIDENCE: The manager said that they had just finished the Service User Guide and Statement of Purpose. There is also a DVD about the service available to new service users. The Statement of Purpose had been amended to take on board the requirements from the last inspection and now included how service users Lisieux House DS0000016994.V275802.R01.S.doc Version 5.1 Page 9 make complaints, with CSCI details included. However this needs some further minor changes to include CSCI address. Both the statement of purpose and service user guide are currently in accessible format for the service user who live in the home. However consideration needs to be given to how accessible these documents are, should the service user group change. The service user guide needs to be in an accessible format for all service users. It would be positive when these documents are reviewed as required annually, that photos of the shared areas, activities available in the locality and day times activities be included in these documents. This would enable prospective service users to gain a good insight into the service prior to having introductory visits. The manager explained that she felt it was really important for service users to make ‘real choices’ about where they live. She described how, she and the staff team supported one service users with their move after a family bereavement. Because of the speed of the move due to family circumstances, they had supported her to have an advocate, also taken her to look at lots of different types of care homes and had a number of meetings with her and her family before she made the decision she wanted to live at Lisieux House. This process took over six months. This was pleasing to see and an important issue to take on-board for all new service users, so they too can benefit from making informed decisions about where they live. A service user who had moved in recently said ‘sometimes other people who live in the home get on her nerves.’ It is important that she is supported through an advocate and discussions with family members and staff, to enable her to raise her concerns and look at ways of addressing them. Lisieux House DS0000016994.V275802.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 Service users are supported with detailed assessments prior to admission, the needs identified are reflected in care plan statements. Enabling service users to be fully supported with their needs. Service users are supported fully to have all the assistance they need to make decisions about the assistance they need, which enables them to have a more independent lifestyle. Service users are supported to ‘feel’ fully involved in the care they receive, through regular consultation in all aspects of their care in the home. Service users are encouraged to be independent as possible and are supported with this, with some risk assessments. This process is not comprehensive there are areas that need further development to ensure all risks are identified and appropriate action is taken. Service users know that information about them is handled appropriately. Giving them confidence to discuss problems and issues with the staff team. Lisieux House DS0000016994.V275802.R01.S.doc Version 5.1 Page 11 EVIDENCE: During the inspection four service user files were sampled. There were lots of examples of positive information kept in the service users files. The service users benefited from comprehensive daily diary sheets, which were completed each shift. One service users said ‘how pleased she was at being able to write her own daily diary sheets every day’. There were examples of good practice, like service users having individual ‘intimate care sheets’, that they had signed up to. The service users benefited from regular reviews, all information in the files was current. There was evidence of monthly reviews forms to be completed with service users key-workers, looking at individual service users aims and goals, although these were not always carried out monthly. Some of the files sampled had consent to medication forms in place, signed up to by the service users. The manager said that that four people had had Person Centred Plans, through the day centre they attended, and that the staff try to work with the service users in a person centred way. It is recommended in line with the Governments national strategy and the White Paper, ‘Valuing People’, that all the service users who live in the home, are supported to have a Person Centred Plan. However, the information in the service user files needs to improve and be comprehensive and consistent, particularly in respect of care plans and risk assessments. The manager said that currently all the files were being up dated to ensure only relevant up to date information was kept in the working files, this meant that on some of the files sampled there were areas yet to be completed. However whilst there are comprehensive care plan statements in place, further development work is required in this area, to produce comprehensive care plans/support plans that detailed individual needs and how they are going to Lisieux House DS0000016994.V275802.R01.S.doc Version 5.1 Page 12 be met. This should be put into a format that facilitates regular reviews, not less than six monthly. Comprehensive care plans/support plans need then be linked into individual risk assessment, providing a comprehensive support package to each service users. It is important that risk assessments and care plans are properly crossreferenced, so that the reader is directed from one to the other in a clear way. The manager needs to develop care/support plans and risk assessments for each service users night time routine. This will ensure all service users needs are properly identified and adequately met. The service user who is over 65 years needs to be kept under constant review, to ensure the staff are aware of his needs, and can continue to meet them. On the day of the inspection staff were observed offering choices appropriately to service users and encouraging them to make their own decisions. On the day of the inspection, no records pertaining to service users were found to be stored inappropriately and all conversations to and about service users by staff were observed to be handled discreetly and appropriately. Lisieux House DS0000016994.V275802.R01.S.doc Version 5.1 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 Service users are supported to take part in appropriate activities, and be a part of their local community. Enabling them to be a valued part of their community. Service users are encouraged to take part in appropriate leisure activities, to support their personal development. Service users are actively encouraged to have and maintain personal and family relationships. Services users are encouraged to advocate for themselves, through staff support and by staff demonstrating they respect service users rights. Staff support service users enjoy a healthy diet, and chose the foods they eat on a daily basis, ensuring service users benefit from a healthy, well balanced diet. Lisieux House DS0000016994.V275802.R01.S.doc Version 5.1 Page 14 EVIDENCE: The service users are able to chose what they do during the day and it was clear form the activity board that is updated weekly, and when necessary throughout the day. All service users took part in a wide range of activities, including, going to the day centre, college courses, work, leisure and social activities and seeing their friends and family. Some service users go out independently, and access public transport. Two service users have chosen to retire now and one service user prefers to do a range of indoor activities, however the staff are working hard with her to broaden her interests. Service users are supported to practice their religion and recently over the Christmas period some of the service users requested a large carol service, many of the service users took part in this. One of the service users said, ‘he enjoys living here and is able to choose the things he likes to do’. He said ‘he had been to work this morning and was going out to club later in the evening’. The staff have recently started to support some of the services users to go to aqua aerobics on a Monday. The service users have been supported to enjoy a number of different holiday choices this year, including a Mediterranean cruise. The manager said the day centre staff and she had worked together to find a work placement at an animal centre for one of the service users, as this is an area of work she would like to get a job in. This placement will be starting shortly. Whilst the inspection was being carried out, several service users left to go to the day centre on their own and with support. One service users was leaving to go to work as the inspector arrived. The home is also currently supporting two service users to develop skills in travel training. It would be beneficial to the service users to record in their individual files their likes and dislikes about activities and activities they would like to undertake in the future. Currently activities are recorded on the activity planner and individual service user daily notes. Staffing levels are still an issue at the home, but the manager said that they have recently recruited five new staff and are currently managing the staffing levels in a number of ways, including the use of regular bank and agency staff. The manager said that they are also able to call on staff from other homes in Lisieux House DS0000016994.V275802.R01.S.doc Version 5.1 Page 15 an emergency situation, this is further supported by having two senior staff on on-call who can come out to the home in an emergency situation. The manager has also made arrangements to have an extra member of staff on duty over the evening periods and on weekends to facilitate leisure activities, however this is not always possible. Staffing levels mean that it can be difficult to facilitate individual activities and often activities need to be undertaken as a group. Service users are supported to know their rights, via service user meetings and individual conversations with key workers and staff, they are able to advocate for themselves, but also in more difficult situations are supported to have advocates, the manager encourages friends and family involvement, who will also advocate for the service users. The service users are supported by staff, to plan and choose their evening meals on a weekly basis. Menu sheets are kept of evening meals, these sheets reflect a balanced diet is offered to service users. Breakfast and lunch choices are kept on the service users daily records, it is required that meal choices are recorded as e.g. Ham salad sandwiches and fruit and drink, rather than as ‘packed lunch’. It may be helpful, to keep record of what service users eat in one central place, making it easier to review this, should there be a necessity. The home demonstrated lots of choices of good quality food, and there was plenty of fresh fruit and vegetables available. The service users take an active role in the whole process of meal times, from planning the menus, to shopping, preparing and cooking the meal. Whilst the inspector was there, she observed, all of the service users taking some active role in getting the evening meal ready. The manager said that, because some of the service users like to eat on their own, service users can choose where they eat, including the dinning room, the kitchen and in the summer, several eating areas in the garden. Lisieux House DS0000016994.V275802.R01.S.doc Version 5.1 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 20, 21 Service users wishes are respected by are receiving personal support in a way they prefer. The homes policies and procedures do not fully protect the services users in the administration of their medication. Services users are supported with plans to meet their wishes in the event of their death, ensuring service users and relativities can be confident their wishes will be respected. EVIDENCE: Four service users files were sampled during the inspection and each file was noted to have, intimate care statements, signed by the service users detailing the way they would like to receive personal care. This process needs to be further developed to support the service users to receive personal care/ support through individual care plans, this will ensure as well as receiving personal support how they prefer, the service users will also receive the support they require. Lisieux House DS0000016994.V275802.R01.S.doc Version 5.1 Page 17 Care/support plans and risk assessments need to be developed for service users who bathe independently, or semi independently to ensure their health and well being whilst using the bathrooms. There have been no further omissions recorded on the service users medication administration records since the last inspection. The manager has undertaken a large amount of work in this area and there is now a robust procedure in place in respect of training and counselling of staff should further mistakes occur. A record is maintained of current medication for each service user. There are records in place demonstrating an audit trail of medication received. All creams and liquids should be dated when opened. The service user files sampled had individual consent forms in place. The homes medication policies and procedures need further development to ensure service users are fully protected under the procedures. PRN protocol forms need to be developed for each and every medication given. FP10 forms needs to be kept with old medication administration records. A recent photograph should be kept on the medication administration records. The manger said that all staff have completed medication training, however staff files sampled did not demonstrate medication-training certificates are in place. The manager said this was because some training certificates were yet to be filed, and they were also waiting on getting copies of certificates from individual staff members. One of the service users said she self medicates. This was not looked at during the inspection. The manager said that all service users and/or their next of kin/representatives had been approached, to ascertain each service user wishes in the event of their death, and there was evidence of this in the service users files. The staff are looking at developing further well women and well men groups so service users understanding what is good health, and what is poor health and can recognise this. Lisieux House DS0000016994.V275802.R01.S.doc Version 5.1 Page 18 It is recommended that this process be further supported, by developing Health Action Plans, for each of the service users. Lisieux House DS0000016994.V275802.R01.S.doc Version 5.1 Page 19 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 Service users are supported to feel confident their views are listened to and acted upon. Policies and procedures with in the home ensure the service users are protected from abuse, neglect and self-harm. EVIDENCE: The service users have between 4 and 6 weekly service user meetings, which are facilitated by an independent volunteer. The services users are supported to take part in monthly key-worker meetings, although files demonstrated these were not always achieved on a monthly basis. The complaints policy is currently being up-dated, this need to include CSCI’s contact details including the address. There have been no complaints since the last inspection; the manager confirmed that all complaints and/or concerns were all now recorded in the complaints log. The manager said that the service users were able to advocate for themselves, in more complex cases the manager has used the services of an advocate. The service users are also supported by family members, who are happy to raise concerns or complaints with the manager. Lisieux House DS0000016994.V275802.R01.S.doc Version 5.1 Page 20 Clearly displayed on the notice board at Lisieux House, were the Lisieux Trusts ‘Bill of Rights’ and the Trusts’ aims and principles. These documents were in an accessible format to the service users. Nearly all staff have attended Vulnerable Adult Protection training courses, certificates of training evidencing attendance, must be kept on individual staff files. A discussion with the manager, demonstrated she had a sound knowledge base in this area. The Trust had in place their own policies and procedures in respect of vulnerable adults, they also had a copy of the Department of Health, white paper ‘No secrets’. It is required that the manager obtain a copy of the Birmingham Multi-agency guide on dealing with adult protection issues, and this is kept on the premises. So that staff can follow agreed health and social services procedures in the event of an adult protection issue. There haven’t been any adult protection issues since the last inspection. On the four files sampled, there were many records pertaining to service users finance, including details of their benefits, a break down in what they had to pay in rent and these were all in accessible format. There were records of service users bank accounts, spending recorded on these, demonstrated there were no inappropriate purchases. However it is required, that all service users have financial risk assessments put in place, which should be signed by the service users where possible, or in cases where they cannot sign, a representative/relative should sign up to these on the service users behalf. Lisieux House DS0000016994.V275802.R01.S.doc Version 5.1 Page 21 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, 25, 26, 27, 28, 29, 30 Service users are supported to live a homely, comfortable, spacious environment that was in an excellent decorative order and is clean and hygienic. The service users bedrooms, are individual personalised and suit their needs and lifestyles. The bathrooms and toilet areas provide a pleasant private area to meet the service users personal care needs. Service users are supported to have the specialist equipment they require to promote their independence. EVIDENCE: A tour of the premises was undertaken, at both properties. The home was decorated to a high standard. The manger described how the service users choose the decorations, and the service users spoken to on the day of the inspection confirmed this. Lisieux House DS0000016994.V275802.R01.S.doc Version 5.1 Page 22 However, there was a small area in the kitchen of Lisieux House, above the table, where there is a need to re-plaster around a plug socket, as currently there are some holes around the electrical socket and this could represent a danger. Three service users showed the inspector their bedrooms; these were filled with personal items like photos, ornaments and pictures belonging to the service users. The bedrooms were nicely decorated and all the service users said they had chosen the decorations. One bedroom was found to be very cold; the service user said she liked it this way. The manager confirmed that the new heating system allowed the service users to chose how warm or hot they liked their own room. Both houses were found to be very clean and tidy. Throughout the inspection, service users were observed to be involved in household chores with staff support, which they seemed to enjoy taking part in. On service users has a hearing problem, and it was noted that in the communal areas of her home, a system to support this had been fitted, for instance in the lounge to help her hear the television. Lisieux House DS0000016994.V275802.R01.S.doc Version 5.1 Page 23 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): 31, 32, 33, 34, 35, 36 A trained competent and qualified staff team meets service users individual and collective needs. The service users are supported and protected by the homes recruitment policy, however practices could be further developed. The service users would benefit, from staff being offered regular supervision and appraisals, where staff roles and responsibilities were regularly explored. EVIDENCE: A sample of three staff files were looked at during the inspection, a number of areas in these files demonstrated they did not correspond fully with schedule 2. Two files sampled did not include a copy of the staff member’s job description and person specification. Not all files had a recent photograph clearly displayed on the file Although there was evidence of training completed in statutory areas, on the training matrix, this required updating to list refresher courses due dates for 2006. The manager was able to show the inspector certificates for staff training, however copies of these had not been places on individual staff files. Lisieux House DS0000016994.V275802.R01.S.doc Version 5.1 Page 24 Not all staff training was inspected; NVQ’s were not looked at during this inspection. It is now required by the regulations that 50 of the work force has completed their NVQ 2 or 3 by the end of 2005. One staff file didn’t have medical clearance in place, and two staff files did not include copies of a birth certificate and passport. On all three staff files looked at, supervision records did not demonstrate that supervision was being carried out at least six times a year. One staff file demonstrated an annual appraisal had not taken place. Lisieux House DS0000016994.V275802.R01.S.doc Version 5.1 Page 25 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, 41, 42, 43 The service users benefit from a generally very well run home, with a consistent management lead. Service users can be confident their views underpin the self-monitoring, review and development by the home. Service users cannot be fully confident that their best interests are safeguarded by the home’s record keeping. The health and safety of the service users is not fully promoted and protected. EVIDENCE: There was evidence in the ‘communication book’, and on supervision notes that the manger regularly updates staff on issues and takes the necessary action to ensure the service users benefit from living in a well manager environment. Lisieux House DS0000016994.V275802.R01.S.doc Version 5.1 Page 26 Through discussions with the manager, observations of her working with staff and sampling records, it was evident that the manger is effective in her role. The manger and the staff team had worked hard to meet nearly all of the last inspections requirements, this inspection was completed only a matter of months ago. Regular fire checks were now completed; there was evidence of fire drills for this year. There was evidence of checks made of the smoke detectors, fire extinguishers and other fire equipment. The manger said that all service users, who it has been noted from drills, have issues with evacuations, now have risk assessments in place. The vehicle documentation was checked and the insurance certificate was seen, there is currently no need for an MOT on the car, this will be due next year. It was noted that the car was not having monthly checks. Some were in place however there was a number of months missing. The manger said as they employ a driver, she was confident these checks were being completed and were probably kept in the vehicle. Water temperatures were not being recorded to a satisfactory standard, and service users did not have risk assessments in place in this area to ensure scalding accidents could be prevented. Service users need to be supported with their care at night, care/support plans and risk assessments must be developed for individual service users to ensure staff are meeting the needs of the service users at this time. Record keeping, in the home needs some improvement, particularly with reference to up to date filing, ensuring information is held in the correct place, and all necessary checks are completed in a comprehensive manner, so to promote and ensure the health and safety of the service users leaving in the home. Lisieux House DS0000016994.V275802.R01.S.doc Version 5.1 Page 27 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 2 2 3 3 3 4 3 5 3 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 2 32 2 33 2 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 3 LIFESTYLES Standard No Score 11 X 12 3 13 2 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 X 2 2 3 3 3 X 2 2 3 Lisieux House DS0000016994.V275802.R01.S.doc Version 5.1 Page 28 Are there any outstanding requirements from the last inspection? No 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 2. Standard YA1 YA9 Regulation 4(1c) 13(4b) Requirement Timescale for action 18/04/05 3. YA9 13(4b) 4. YA20 13(2) The Statement of Purpose must include details of the CSCI’s full address. The registered manger must 31/03/06 ensure all service users are supported to have individual nighttime care/support plans and corresponding risk assessments. The registered manager must 09/06/06 ensure that all service users have comprehensive individual care/support plans, which can be easily cross- referenced with the corresponding risk assessment. Care/support plans should be provide a detailed specific plan that gives clearly identifies support needs and actions on how these will be met. These should be clearly reviewed not less than every six months. The registered manager must 31/03/06 ensure that medication is administered as prescribed by the GP. All medication records need to have a recent photo of the service users on the front of each file and PRN protocols must be in place for all PRN medications. DS0000016994.V275802.R01.S.doc Version 5.1 Lisieux House Page 29 5. YA32 18(1a) 6. YA32 18(1a) Sch2(4) 7. YA34 7 9 19 Sch2 8. YA36 12(5) 9. YA42 13 17 Sch414 23 10. YA42 23(2p) 11. YA42 4(a) The registered manager should 50 of the work force need to have completed their NVQ 2 or 3 by the end of 2005. The registered manger must ensure that training matrix corresponds with staffs individual training records, and that records of all staff’s individual training is kept on their file. The training matrix needs to be upto-dated and reflect when refresher courses are due, the name of the organisation carrying out the refresher training must also be include. The registered manger must operate and adhere to a robust recruitment system and ensure that staff records include those items stated in Schedule 2 of the Care homes regulations for inspection. The registered manager must ensure that staff are required to have at least six formal supervision sessions a year. The registered manager must ensure that all precautions are taken against the risk of fire in the bungalow as well as the house, including a fire risk assessment and recording of routine checks. Not assessed fully on this inspection. The registered manager must ensure water temperatures are checked weekly, from each water outlet and there are both generic and individual risk assessments in place, for the use of the kitchen taps, which is not supported by a safety valve controlling the temperature of the water. The areas of missing plaster, around an electrical plug socket, DS0000016994.V275802.R01.S.doc 30/09/06 31/03/06 18/03/05 30/06/06 10/10/06 16/01/06 09/02/06 Lisieux House Version 5.1 Page 30 in the kitchen of Lisieux House, must be re placed via replastering. 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. 3. Refer to Standard YA7 YA19 YA19 Good Practice Recommendations All services users need to be supported to have a Person centred Plan. The service users should be supported to have individual health action Plans. Service users should be weighed monthly, enabling staff to be effective in picking up on early warning signs of changes in their health and well being. Where this is not possible reasons for this should be clearly recorded on service users files. 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 Arrangements for a private lockable area/door/storage should be considered with service users in the bungalow. Not inspected on this occasion. The registered manger should ensure vehicle checks are carried out at least monthly. 4. YA24 5. 6. YA26 YA42 Lisieux House DS0000016994.V275802.R01.S.doc Version 5.1 Page 31 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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