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Inspection on 18/10/07 for Littleover Lane Residential Care Home

Also see our care home review for Littleover Lane Residential Care Home for more information

This inspection was carried out on 18th October 2007.

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

The inspector found 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

Of the seven requirements left at the last inspection, six of these have been met. The service users have taken two separate holidays this year with staff support. Staff and service users who attended said these were very enjoyable. A conservatory is in the process of being built, this will become the designated smoking area for service users who smoke.

What the care home could do better:

The manager must apply for registration with the commission, as it was confirmed that this post has now been agreed as a permanent position. More stringent measures must be in place regarding medication practices to ensure the welfare of service users is demonstrated. Good quality assurance systems are in place but a system for feedback to service users, relatives and other interested parties needs to be developed to demonstrate this.

CARE HOME ADULTS 18-65 Littleover Lane Residential Care Home 44 & 44a Littleover Lane Littleover Derby Derbyshire DE23 6JG Lead Inspector Angela Kennedy Unannounced Inspection 18th October 2007 10:30 Littleover Lane Residential Care Home DS0000001985.V347622.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 Littleover Lane Residential Care Home DS0000001985.V347622.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. Littleover Lane Residential Care Home DS0000001985.V347622.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Littleover Lane Residential Care Home Address 44 & 44a Littleover Lane Littleover Derby Derbyshire DE23 6JG 01332 270154 F/P 01332 270154 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) H46013@mencap.org.uk Royal Mencap Society Vacant Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Littleover Lane Residential Care Home DS0000001985.V347622.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th November 2006 Brief Description of the Service: Mencap lease Littleover Lane. The accommodation comprises of two houses, which provide personal care for up to 9 service users with a learning disability, aged between 18 and 65 years of age. Five service users occupy house number 44, and four service users live at house number 44a. Both houses have been furbished to reflect the style of a family home. Both houses have an accessible garden, which is segregated with a garden fence and a gate separating the patio areas. Each house is run independently, in accordance with service user needs. The weekly fees ranged from £576 to £700. Items not included in this fee were: Personal items and clothing purchased Toiletries Social and community activities A contribution of £111.00 was given to each service user towards their annual holiday. Littleover Lane Residential Care Home DS0000001985.V347622.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over two days, as on the first day the manager was not on duty and therefore certain information such as staff recruitment documents were not accessible. The inspection visits in total lasted approximately seven hours. Key inspections take into account a wide range of information and commence before the site visit by examining previous reports and information such as any reported incidents. The site visit is used to see how the service is performing in practice and to meet with the people using the service. The inspection was focused on assessing compliance with defined key National Minimum Standards. The commission had requested the service to complete an Annual Quality Assurance Assessment, however this document had not been returned to the commission prior to this inspection visit. Two of the service users that lived at 44 Littleover Lane were spoken with on the first day of the inspection visit. One of these service users was also case tracked. Both of the service users spoken with confirmed they were happy with the support and care they received at Littleover Lane and both said they liked living there. Two service users were case tracked; one service user lived at 44 Littleover Lane and the other at 44a Littleover Lane. The service user that was case tracked that lived at 44a Littleover Lane was unable to verbally confirm there opinion of the service and care provided to them. However this service user was seen on the second day of the inspection visit and from observation appeared relaxed and comfortable. Case tracking is a method used to track the care of individuals from the assessments undertaken before they are admitted to a service through to the care and support they receive on a daily basis. This includes looking at support plans and other documents relating to that persons care, talking to staff regarding the care they provide and if possible talking to the individual. What the service does well: Person Centred Plans were in place that were comprehensive in detail and specific to individual needs and choices. Littleover Lane Residential Care Home DS0000001985.V347622.R01.S.doc Version 5.2 Page 6 Although the majority of service users have high support needs staff are supportive and encourage each person to be as independent as possible and make decisions and choices regarding their life. Both houses were homely and the décor demonstrated the individual service users choices and preferences. All of the service users seen appeared relaxed and at home, and for those who were able to converse, they spoke highly of their home and the support offered to them and provided by the staff team. What has improved 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. The summary of this inspection report can be made available in other formats on request. Littleover Lane Residential Care Home DS0000001985.V347622.R01.S.doc Version 5.2 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 Littleover Lane Residential Care Home DS0000001985.V347622.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that service users needs are fully assessed and met prior to admission. This ensures the service is confident that they can meet each individual’s needs, before admission is agreed. EVIDENCE: Four service users were living at 44a Littleover Road and four at 44 Littleover Road. The majority of the service users who are admitted to the home have their needs assessed by social workers or through the care management system. The assessments then form part of the service user’s plan compiled by the home. Seven of the service users were admitted to the home prior to 1999, and their initial needs assessment have been archived. There was evidence that the placing Authority reviews the care needs assessments on a regular basis. One service user had moved into 44 Littleover Lane since the last inspection and there was sufficient evidence in place to demonstrate that a needs assessment had been undertaken prior to their admission. Littleover Lane Residential Care Home DS0000001985.V347622.R01.S.doc Version 5.2 Page 9 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): 6,7,9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The detailed support plans in place demonstrated that service users individual needs were met. EVIDENCE: The person centred support plans of the two service users case tracked were looked at and covered all areas of each individuals assessed needs. One service user had a total of 47 support plans and the other 48 support plans. This demonstrates that each specifically identified area of support was addressed. The detail provided in each support plan was good and pictorial descriptions were used to enable service users to understand the areas of support that were being addressed. Littleover Lane Residential Care Home DS0000001985.V347622.R01.S.doc Version 5.2 Page 10 All support plans included each person’s individual lifestyle preferences and choices; the interventions prescribed by outside healthcare professionals were appropriate. The support plans were personalised and had been complied with the service users together with friends and /or the Advocacy Service. Support plans were written from the service users point of view, and for service users who were unable to sign their support plans this was recorded and signed by a member of staff. Daily records were also maintained on each service user. Both service users spoken with said that the staff team supported them in their daily lives and confirmed that they were involved in developing and reviewing their support plans. The system for handling service users personal monies was examined and there was confirmation that there are suitable accounting procedures in place. Detailed risk assessments were in place and these included actions to be taken by staff. Littleover Lane Residential Care Home DS0000001985.V347622.R01.S.doc Version 5.2 Page 11 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): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service user maintained relationships with family and friends, and participated in activities both in the home and outside in the wider community, in accordance with their preferences and wishes. This demonstrates that service users independence and personal choices regarding activities and relationships was supported and promoted by the staff team. EVIDENCE: The two service users case tracked had detailed support plans and assessments in place regarding their social, recreational, educational and occupational activities both within the home and outside in the community. Service users are unable to work due to their level of disability, however some of the service users attended the local day opportunity placements either full Littleover Lane Residential Care Home DS0000001985.V347622.R01.S.doc Version 5.2 Page 12 time or on a part time basis. The service users’ personal goals, choices and preferences were identified and risk assessments were in place for each service user in relation to the activities they were engaged in. Two separate holidays had been undertaken for the service users and staff had supported service users on these holidays. One holiday was taken in York and the other in Norfolk. The manager confirmed that all but two of the service users had been on holiday. The two service users who had not participated were unable to due to ill health at the time of the holidays. Information on service users’ records demonstrated that a positive relationship and good communication was maintained with service users families. Two service users spent time with their families on a weekly basis. From examination of the menus the home is providing a healthy well-balanced and nutritious diet. Service users, who wish to, undertake the food shopping with staff support and the meals prepared are based on service users individual preferences. Pictorial formats were used to enable service users to identify the various meals to choose from. The two service users spoken with said they enjoyed the meals at Littleover Lane. Littleover Lane Residential Care Home DS0000001985.V347622.R01.S.doc Version 5.2 Page 13 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): 18,19,20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users health care needs and independence are promoted through detailed support plans and staff practice. The medication practices in place do not fully demonstrate that service users are protected. EVIDENCE: Service users personal care needs and how they were to be met were recorded in their support plans. Support plans and records held demonstrated that service users health care needs were met. Service users were supported to access health care services, such as G.P appointments and hospital visits and evidence was in place to demonstrate that annual health checks were undertaken. Service users records showed that staff promptly contacted the appropriated medical services, as and when required. All service users attended services within the community including optician, podiatry and dentist. None of the service users were able to administer their own medication. All staff had received training on medication dispensing procedures and annual Littleover Lane Residential Care Home DS0000001985.V347622.R01.S.doc Version 5.2 Page 14 refresher training was also provided to staff, to ensure they were kept up to date with medication procedures. The arrangements for receipt, storage, administration and disposal of medication were also examined and found in general to be satisfactory. However it was noted on one service users medication administration record, that the instructions for one prescribed medication that was to be given three times a day stated that it had been ‘discontinued by parents’. Following discussions with the manager it was stated that this medication had been altered by the service users G.P and was now given as an ‘as required’ medication. Discussions took place with the manager regarding the importance of ensuring that medication administration records are updated following any changes to prescribed doses, and medication administered should show the correct times the medication is to be administered, as the pharmacy label still stated this medication was to be administered three times a day. With regard to the instruction seen ‘discontinued by parents’ the manager must ensure that any amendments to medication administered must only be done so in consultation with the service users G.P and evidence must be in place to demonstrate that this has been done and that the G.P is in agreement. If circumstances arise where the opinion of parents differs regarding the prescribed medication dose, then a full consultation should take place with the manager, G.P and parents involved, and records must be held to demonstrate the discussions held and the outcome. Littleover Lane Residential Care Home DS0000001985.V347622.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A proactive and positive approach with regard to concerns and complaints ensures that the views of service users and their representatives are taken seriously. The practices and policies in place ensure the welfare and safety of service users is enhanced. EVIDENCE: The home has a complaints procedure with a summary and a complaints form included in the service users guide, which all service users have a copy of. Mencap have developed a format which is accessible to service users as several of the service users are not able to fully communicate their concerns. Derbyshire Advocacy Service is used by the service, and they support the service users in making complaints should they wish to do so. The Commission for Social Care Inspection has received no complaints about this service since the last inspection. The service users that were spoken with said they had no complaints about the home and confirmed that they would speak to a member of staff if they had any concerns. Littleover Lane Residential Care Home DS0000001985.V347622.R01.S.doc Version 5.2 Page 16 The complaints procedure contains the recent Derbyshire local office address of the Commission for Social Care Inspection. This now needs to be amended to show the Nottingham office address. On examination of the records there was evidence to demonstrate that a proactive approach was provided to any concerns or complaints made. An example of this was following a concern raised by a service users family regarding communication with the staff team, which resulted in staff training that included consultation and inclusion of the service users family at the training session. The manager stated that this proved to be a positive exercise, which resulted in a greater staff awareness of this families needs. No reported incidents or allegations under the safeguarding adults procedure have been made since the last inspection. Records demonstrated that all staff had completed training on Safeguarding Adults and refresher courses were provided as required by the registered manager of another Mencap service, who has been trained by the Local Authority to provide this training. The Safeguarding Adults policy was looked at and was in line with the Local Authority procedure and protocol. As the Local Authority are the lead investigators in Safeguarding referrals and investigations this indicates that the correct procedures would be followed in any safeguarding issues. Littleover Lane Residential Care Home DS0000001985.V347622.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,28,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The general standard of both houses and the environment are good providing service users with an attractive and comfortable place in which to live. EVIDENCE: A tour of the home was undertaken and all communal areas and some bedrooms were seen. The staff are required to do sleep in duty in one of the houses, the other house has a waking night staff. Both homes are comfortable and reflect the service users individual preferences and choice of decoration. Both of the service users spoken with confirmed they were happy with the décor of their home and standards of hygiene in place. Littleover Lane Residential Care Home DS0000001985.V347622.R01.S.doc Version 5.2 Page 18 At the last inspection visit it was confirmed that service users had raised concerns regarding secondary smoking. As two service users smoke in one of the houses, which accommodates another two service users. As a temporary measure the service users that smoke have been asked to do so outside and a sheltered area has been provided. A conservatory was being built to the rear of this home at the time of the inspection visit, which will become the designated smoking area for the two service users that smoke. A smoking policy was now in place at the home and this was seen at the inspection visit. In this home two of the service users were unable to access the stairs due to mobility needs, therefore their bedrooms were situated on the ground floor and a living room and dining area were provided on the ground floor, along with a kitchen and shower area and toilet. For the other two service users living at this house a living room with drinks facilities was situated on the first floor. In the other house discussions took place with two of the staff regarding plans for a new bath that would provide access for two of the service users living there. On the first day of this inspection visit a member of staff had attended a demonstration regarding this bath and discussed this with the inspector on return. The laundry facilities were seen and discussions took place with staff and the manager regarding the washing machine in place, and if a machine with a built in sluicing facility was needed. It was stated that at present the laundering of service users clothes and bedding are laundered satisfactorily. However consideration should be given to the purchase of a washing machine with a built in sluicing facility when a new machine is purchased. Littleover Lane Residential Care Home DS0000001985.V347622.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The recruitment procedures and practices in place were in general good, but not all records were in place to fully demonstrate this. Importance is given to the staff’s developmental and training needs. This ensured staff had the skills required to ensure service users needs could be met. EVIDENCE: The home operates a key-worker system and the staff spoken with during the visit where aware of the individual needs of the service users. From records examined and from discussions with the manager it was confirmed that out of the twelve staff employed, four have achieved a National Vocational Qualification at level 2, two have an NVQ at level 3, and three staff are working towards NVQ level 3. The recruitment documents for two members of staff were looked at and in general contained all of the required information. However one staff file did not contain the two required references. The manager stated that these would have been sent to the personnel department and copies had not been made for the staff file kept at the home. Littleover Lane Residential Care Home DS0000001985.V347622.R01.S.doc Version 5.2 Page 20 To demonstrate the correct recruitment procedure has been followed there must be evidence in place within staff files of all documents received. The staff training records were seen and in general were up to date. Some staff were due to undertake further mandatory training and the manager stated that this was in the process of being arranged. Staff spoken with felt that the training provided by the service was of a good standard and enabled them to support and meet the service users needs. At the last inspection, and at this inspection visit it was stated by staff, that some supervision sessions had been cancelled due to the manager’s workload. Discussions took place with the manager regarding this and the manager showed the inspector dates within the near future when staff supervision had been booked. Discussions regarding informal supervision also took place and it was evident that this takes place on a regular basis. It was agreed by the manager that these discussions could be recorded to demonstrate that they had taken place. Staff spoken with stated that the manager was supportive and was always willing to listen to their opinions and any concerns or issues they had. A new induction package was in place at the service, which was in line with Skills for Care. Littleover Lane Residential Care Home DS0000001985.V347622.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well managed, which ensures that it is run in the best interests of service users and enables their health and safety to be promoted and protected. EVIDENCE: The manager in post at Littleover Lane has moved from another Mencap service and has not yet applied with the Commission to be Registered as the manager for Littleover Lane. Discussion took place regarding the need for this to be done within the near future. Littleover Lane Residential Care Home DS0000001985.V347622.R01.S.doc Version 5.2 Page 22 The organisation has effective quality assurance systems in place. Mencap complete an internal audit/review of the service and a comprehensive report with recommendations is sent to the home. Service user meetings were usually held on a monthly basis and chaired by an independent advocate from Derbyshire Advocacy Services. The manager confirmed that these meetings had not taken place for the last three months, due to the advocate being off sick. However it was confirmed that another member of Derbyshire Advocacy services had visited the service users at Littleover Lane on an informal basis every fortnight to enable them to discuss any concerns or issues they had. Meetings were also held across the different Mencap services, and managers, support staff and service users from different Mencap homes were invited. Two of the service users from Littleover Lane had attended the last meeting with staff support. Service users were also involved in the recruitment of staff and one of the service users had recently been involved in staff interviews and had telephoned the successful candidate to offer them the post. The service users, relatives and stakeholders are sent questionnaires in order to obtain their views of the running of the home. However the Manager was unsure as to whether the findings are made public. The service/maintenance documentation seen indicated that service users are protected by robust procedures, with all evidence of gas and electrical services having been suitably checked/maintained. Fire training for staff was undertaken twice a year, the manager stated that fire training would now be taking place every three months for all staff. The training provided would be alternated every three months from a fire C.D with a questions and answer at the end, training from an external company and a questions and answers module completed through distance learning. Discussions took place regarding the infection control measures in place. The manager confirmed that infection control was included in induction training, but was unaware of any other infection control training provided through Mencap. A Health and Safety policy was in place and this policy addressed infection control. No infection control assessment had been undertaken at Littleover Lane, information was given to the manager regarding infection control assessments and how these can be accessed via the Department of Health Website. Littleover Lane Residential Care Home DS0000001985.V347622.R01.S.doc Version 5.2 Page 23 All staff had undertaken first aid training. The guidance regarding care homes providing first aid has recently been amended and allows services to undertake a first aid risk assessment specific to their individual service. Information pertaining to the factors that can be taken into account and the criteria for who can be regarded as a qualified first aider were given to the manager at this inspection visit. However if a risk assessment is not in place the Commission will require that someone who has undertaken a suitably approved first aid at work qualification be on duty at all times. Littleover Lane Residential Care Home DS0000001985.V347622.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 4 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 3 X Littleover Lane Residential Care Home DS0000001985.V347622.R01.S.doc Version 5.2 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 12 Requirement Medication administration records must be updated following any changes made by the G.P to the prescribed dosage or times that medication is to be given. Any alterations or decisions to discontinue prescribed medication must only be done following consultation with the G.P and written evidence must be in place to demonstrate this. To demonstrate the correct recruitment procedure has been followed there must be evidence in place within staff files of all documents received. Timescale for action 01/01/08 2. YA20 12 01/01/08 3. YA34 19 1 (b) 01/01/08 4. YA37 5. YA39 Care The manager must apply for 18/01/08 Standards registration with the commission. Act 2000 Section 11 (1) 22 The results of any reviews 18/02/08 conducted by the service must be made public. (Previous timescale given 31.12.06) Littleover Lane Residential Care Home DS0000001985.V347622.R01.S.doc Version 5.2 Page 26 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 YA36 YA42 Good Practice Recommendations The Registered Manager should reschedule any staff supervision, which has been cancelled. An assessment of the Infection Control measures in place should be undertaken. Littleover Lane Residential Care Home DS0000001985.V347622.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Littleover Lane Residential Care Home DS0000001985.V347622.R01.S.doc Version 5.2 Page 28 - 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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