Inspection on 12/10/07 for Lyons Gardens

This inspection was carried out on 12th October 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lyons Gardens 07/12/06

Lyons Gardens 06/04/06

Lyons Gardens 19/09/05

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Lyons Gardens 36 Lincoln Road Glinton Peterborough PE6 7JS Lead Inspector Nicky Hone Unannounced Inspection 12th October 2007 10:35 Lyons Gardens DS0000063991.V353075.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 Lyons Gardens DS0000063991.V353075.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. Lyons Gardens DS0000063991.V353075.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lyons Gardens Address 36 Lincoln Road Glinton Peterborough PE6 7JS 01733 254261 01733 254263 lyonsgardens@herewardcare.co.uk 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) Hereward Care Services Ltd Roslyn Sadie Stone Care Home 11 Category(ies) of Learning disability (11) registration, with number of places Lyons Gardens DS0000063991.V353075.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users with a learning disability who also have a physical disability or mental disorder may be admitted 7th December 2006 Date of last inspection Brief Description of the Service: Lyons Gardens is a purpose built care home on the outskirts of the village of Glinton, about six miles north of the centre of Peterborough. The home consists of two bungalows which are set back from the main road through the village. Each bungalow has a lounge, dining room, kitchen, toilets, bathroom and shower room as well as a laundry, office and staff facilities. One of the bungalows has five single bedrooms, the other has six. All the bedrooms have an ensuite toilet and washbasin. There is parking space at the front of the bungalows and a large paved patio area between the two. There are also grassed garden areas where service users play a number of outdoor games. The bungalows were commissioned by the Greater Peterborough Primary Care Partnership, to replace an outdated home, and the places are all used for respite care. One bungalow offers accommodation to people who have a greater need for support with their physical care needs. The home has its own minibus, but is also located on a bus route. Peterborough, with its range of facilities such as restaurants, pubs, shops and leisure facilities is within a short drive. People stay at Lyons Gardens for varying periods of time, from four nights a week to one night a month. Sometimes people stay at Lyons Gardens for several weeks while other accommodation is being found for them. Currently there are about fifty people who receive a service at the home. The home accepts service users whose ages range from 18 to 65. Currently there are quite a lot of service users who are making the transition from children’s services to adult services. All eleven places at the home are ‘block-booked’ by Greater Peterborough Primary Care Partnership: one of the directors said that £1326.00 per week is paid for each place (from 01/04/06). Each service user pays a contribution towards this cost, from benefits. There are no other additional charges, except a contribution towards some of the outings. Lyons Gardens DS0000063991.V353075.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. For this inspection we (the Commission for Social Care Inspection) looked at all the information that we have received, or asked for, since the last key inspection. This included: • The AQAA (Annual Quality Assurance Assessment) that the manager completed and sent to us in September 2007. The AQAA is a selfassessment that focuses on how well outcomes are being met for people using the service. It gives the manager the opportunity to say what the service is doing to meet the standards and regulations, and how it can improve to make life even better for the people who visit the home. The AQAA also gives us some numerical information about the service. We discussed with the manager that he should put more detail in the AQAA so that we get a fuller picture of the service. Surveys which we sent to people who use the service, their relatives/carers, and staff. We received a total of eighteen replies: eight from people who use the service; six from relatives; and four from staff. Overall, the people who replied were satisfied with the service. What the service has told us about things that have happened in the service, these are called ‘notifications’ and are a legal requirement. Reports sent to us by the provider following monthly visits they have to make to the home. • • • We visited the home on 12/10/07 from 3.15 in the afternoon to 8.15 in the evening and talked with people staying there, some of the staff and the manager. We looked round both bungalows, and checked some of the records the home has to keep. The manager, Paul Gale, was not on duty when we arrived, but came to the home to meet us. Paul had started as acting manager at Lyons Gardens a week before our last inspection in December 2006. In July 2007 Paul was appointed as manager. He has not yet submitted an application to CSCI, so is not registered, but we refer to him as ‘the manager’ throughout this report. Lyons Gardens DS0000063991.V353075.R01.S.doc Version 5.2 Page 6 What the service does well: We have judged that Lyons Gardens has continued to improve the service it offers to the people who visit for their respite stays. The home is managed well, staff are good at their jobs, and people who visit the home enjoy the time they are there. The responses to the survey included many positive comments: some are repeated here. “I am happy when I go there and I always have a lovely room. They let me help them in the kitchen and they take me out for days.” In the survey, we asked “what do you feel the care home does well?” One relative wrote “Everything. I can’t praise Paul and his staff enough, they work so hard and are there whenever you need them…..I couldn’t wish for my relative to be in better care.” When asked “How do you think the home can improve?” this person said “They can’t. The food’s great, the place is really clean, the bedrooms are really clean, the place is spotless and it doesn’t matter when you go. The place is always the same and the staff really make you feel welcome when you come to visit. Just tell them from me to keep up the good work”. “I have never had a problem with the home, it is a wonderful place for my relative to go……staff are wonderful”. “My relative is always happy to go for his weekends – he looks forward to going and meeting his friends. They treat my relative as an individual and grown up – has choices. Happy atmosphere.” “My relative always seems happy to be going, and well cared for when he comes home”. “It’s well laid out, home always clean, and a happy atmosphere”. “The carers look after our relative very well, and we have all the confidence in them. Lyons Gardens is a lovely place, modern and roomy, and always fresh and clean. We are very pleased with the staff and our relative is very happy to go on respite. They are always friendly and nice.” “Excellent! It’s a lovely clean place to live with caring staff always ready to help and listen to my concerns. Should be more homes like this one. The manager is very helpful and understanding. Full marks!” Lyons Gardens DS0000063991.V353075.R01.S.doc Version 5.2 Page 7 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. Lyons Gardens DS0000063991.V353075.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 Lyons Gardens DS0000063991.V353075.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, 5 People who use this service experience adequate quality outcomes in this area. The home makes sure it has a detailed assessment of each person’s needs so that people can be sure they will get the right support. However, the home is not working within its statement of purpose, and people who use the service do not have a contract. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: For this inspection we looked at the records the home keeps about two of the people who use the service. We found full, detailed assessments on both files. This shows that the home makes sure it has information about each person, before they stay at the home for the first time, so that their needs can be met. Each new person to the service is invited to visit as many times as they want to, and have an overnight stay, before they start their respite programme, so that they can feel comfortable with the home. The home continues to have weekends where the group of people using the service are younger people, so that activities over the weekend can be geared to that age group, and they can spend time with people close to their own age. Lyons Gardens DS0000063991.V353075.R01.S.doc Version 5.2 Page 10 In its statement of purpose, the home says “It is acknowledged that shortterm placements of up to 6 months may be made in the event of family crisis / family breakdown for family/carer illness etc.” Two of the people at Lyons Gardens have been living there for longer than six months. One of those people has lived at the home for over a year. The home must make sure it works within its statement of purpose, and that the statement is a true reflection of the service being offered. If the home decides to change the information in the statement, it should ensure that the service offered is in each person’s best interests. There was no contract/statement of terms and conditions, agreed between the home and the person using the service, on the files we looked at. The manager told us that people do not have a contract/statement of terms and conditions with the home. This means people cannot be clear about what they can expect from the home. Lyons Gardens DS0000063991.V353075.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, 9, 10 People who use this service experience good quality outcomes in this area. Care plans have improved and for the most part give staff clear guidance about how each person wants to be supported. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The staff team has worked hard to improve the way care plans are written, and the information in them. The manager explained that this work is still ongoing: because people stay at the home for such a short time (sometimes just one night), and because there are about 50 people who use the service. Each person has a ‘personal profile’ which lists all areas of care plus a brief description of whether that person needs support in that area. If support is needed, the profile directs the reader to a care plan and/or to a risk assessment. For example, ‘Dressing’: if the profile says the person needs some support when dressing, a care plan would be in place to give details of Lyons Gardens DS0000063991.V353075.R01.S.doc Version 5.2 Page 12 what support is needed. If any risks with this had been identified, then a risk assessment would be in place. The individual plans state the ‘need’ and the expected ‘outcomes’ in each area of care, plus guidance to staff on how to achieve the outcome. Staff sign each of the plans to show that they have read and understood them. We looked at the records for two people. The plan for one person was good, giving enough detail for staff to meet his needs. The second care plan also had detailed guidance for staff, for example about dealing with continence. This plan included the size and type of pad the person uses, what to use to clean the person’s skin, what to be aware of when rolling the person on the bed, and so on. There was a cross reference to a risk assessment about using the hoist. The personal profile for the second person mentioned that thickener is needed in the person’s drinks. There was no reference to this on the detailed care plan and no cross reference to a risk assessment. We found that there was some confusion on some of the care plans we saw, between ‘need’, and ‘outcomes’. A member of staff who talked to us, and one who answered our survey, said things have changed for the better over the past year. They told us that the people who use the service are now being offered more choices and are able to make more decisions about the way they lead their lives. People are given a key to their bedroom, and personal information about people is kept securely. Lyons Gardens DS0000063991.V353075.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): 11, 12, 13, 14, 15, 16, 17 People who use this service experience excellent quality outcomes in this area. People have fun at Lyons Gardens, with plenty of opportunities to do interesting things. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The opportunities for people to do things while they are staying at Lyons Gardens has improved since we last visited the home. During the week, people continue to go to the day services they usually go to. Activities during the evenings and at weekends are organised by the staff at Lyons Gardens, and are based on what people have said they would like to do. The home has its own mini-bus, and people also use the local bus service to go to Peterborough, or hire a taxi. The staff encourage people to walk around the Lyons Gardens DS0000063991.V353075.R01.S.doc Version 5.2 Page 14 village, and as far as McDonald’s on the outskirts of the village. Outings that have taken place include to garden centres, restaurants, pubs, picnics, Peterborough cathedral, Ely, Holbeach, Billing Aquadrome, Yarmouth and so on. One weekend, some staff drove three of the people who were staying to Blackpool. They spent the day there, stayed to see the lights, and drove home. It was a very long day, but enjoyed by everyone who went. Staff shifts have changed so that activities do not have to end in the middle of the afternoon because staff have finished their shift. A local night club holds an evening disco for people with disabilities about once a month. People can go if they want to. They have returned home as late as 2a.m., having had a really good evening. The manager said people are able to be the DJ (disc jockey) for part of the evening if they want to. The local pub is now more welcoming than it was when the home first opened. People are supported to choose and pay for their own drinks. A group of people, with staff support, walked to the pub for a drink on the evening we visited. The manager said that the menus have been worked out by the people who use the service. The meals people want on the menu were discussed in residents’ meetings and the menu written. The printed menu was then given back to people to make sure it was right. The menus have changed since our last inspection and people who stay at Lyons Gardens are encouraged to eat healthy meals. The menu is kept as the record of food that has been eaten, with any alternative meals and who ate them also listed. This is a good record. People who stay at the home can also choose to have a take-away meal some evenings if they want to. People are also encouraged to help with shopping if they are at home during the day, preparation of the meal and clearing up afterwards. We saw people helping to cook the meal and other people setting tables, washing/drying up, and putting stuff away. Staff and people staying at the home were all doing their bit, and all having a good time in getting the chore done. Lyons Gardens DS0000063991.V353075.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, 20 People who use this service experience good quality outcomes in this area. Staff treat people well and deal with medication properly so that people are kept safe. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Care plans show that people have been involved in deciding how they want to be supported with their personal care, and all except one of the responses to the survey indicated that people have no concerns about this. One relative said, “there are times when our relative needs more attention to his personal hygiene”, but added that overall they are reasonably happy with their relative being at the home, and that he is happy there. We discussed this with the manager. As people are only at Lyons Gardens for a respite stay, their families retain responsibility for any health appointments. If these fall during their stay then staff from Lyons Gardens will support the person to attend, if the family is not Lyons Gardens DS0000063991.V353075.R01.S.doc Version 5.2 Page 16 able to. People receive treatment in an emergency from the local doctors and district nurses. We visited the home on a Friday and several people arrived from their day services to stay at the home for the weekend. We saw that each person who takes medication brings it with them. Most of the information for people who visit the service regularly is on computer, so a new MAR (medication administration record) chart is printed off each time and a check is done to make sure there have been no changes. The medication is stored securely, either in the office, or in a locked drawer in the bedroom for people who manage their own medication. Any medication left at the end of the stay is recorded on the MAR before it is sent home. Staff have worked with one person to support him to take his medication himself, which he now does. One of the two people whose records we looked at has no medication other than suppositories when needed. We saw evidence that two of the senior staff have been trained to give suppositories: the manager said the district nurses will come in if neither of these two staff are around when the treatment is needed. One person who visits Lyons Gardens is fed through a tube into their stomach. Staff have been trained by a nurse who works for the company which supplies the equipment and the food. The manager said the company is excellent, with someone on-call for any emergencies at any time of the day or night. Lyons Gardens DS0000063991.V353075.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, 23 People who use this service experience good quality outcomes in this area. People are confident their views are listened to. Not all staff are trained well enough in Safeguarding Adults to make sure people are safe from harm. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There is a copy of the complaints procedure in each bedroom. People we spoke with and those who answered our survey said they would be happy to speak to staff or the manager if anything was wrong. They felt confident any issues would be resolved. Staff training records show that sometimes staff wait for some time before they are able to get on a Safeguarding Adults (formerly POVA) course. In which case, Safeguarding should be included in the list of topics covered in induction, which it currently is not. Paul said he would make sure this happens. The home keeps a small amount of money for people while they are staying at Lyons Gardens, if that is what the person wants. We checked two people’s money and transaction records and they were correct. Lyons Gardens DS0000063991.V353075.R01.S.doc Version 5.2 Page 18 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, 30 People who use this service experience good quality outcomes in this area. Lyons Gardens offers people a modern, comfortable, clean, spacious and well designed place to stay. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: We had a quick look round both bungalows. It was lovely to see fresh flowers in the hallways, and fresh fruit in the dining rooms. The shower rooms are now being kept free from mould which is a great improvement. Generally, the home was reasonably well decorated. However, the manager told us that the decorators would be arriving at the home in November and would be decorating right through both bungalows. He said that the people who stay at Lyons Gardens had helped to choose colours. The carpet in the hallway of one of the bungalows is badly stained. Lyons Gardens DS0000063991.V353075.R01.S.doc Version 5.2 Page 19 Apart from the carpet mentioned above, all areas of the home that we saw were clean and there were no unpleasant odours. The gardens surrounding the home looked tidy for the time of year. Lyons Gardens DS0000063991.V353075.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 People who use this service experience good quality outcomes in this area. People who stay at Lyons Gardens benefit from a staff team that is recruited well, and is trained and supported to be able to do their job properly. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The number of staff on duty varies with the number of people who are staying at the home. Staff on duty said that usually there are plenty of staff to make sure people can do what they want to do. We looked at the information the home keeps about two members of staff. One person has worked at the home for a long time and transferred from Peterborough City Council. The other person started in early 2007. All the information the home has to have before a person can start work was on the file. One of the people who uses the service has his own one-to-one carers who come with him. These staff are employed by another organisation, not by Lyons Gardens DS0000063991.V353075.R01.S.doc Version 5.2 Page 21 Lyons Gardens. We were concerned that the manager has no information about theses staff and no evidence that all the necessary pre-employment checks have been undertaken. Staff said there are very good opportunities offered by the company for training in a wide range of topics, and staff are able to say if there is any other training they would find useful. One person said she would like to know more about epilepsy. The manager keeps a training matrix, which showed that the majority of staff have done almost all the courses offered. Certificates to confirm this were seen on the files we looked at. In the AQAA the manager said that more than 50 of the staff are trained to at least an NVQ level 2 in care. The manager told us he supervises all the staff himself: this was confirmed by records of supervision on staff files, and by staff who said supervision happens regularly, and so do staff meetings. Lyons Gardens DS0000063991.V353075.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41, 42 People who use this service experience good quality outcomes in this area. The home is managed well so that people receive a good quality service. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Paul Gale has worked as manager of Lyons Gardens since December 2006, having been a deputy manager in another Hereward care home for a number of years. He started as acting manager and was appointed to the post in July 2006. He has not yet applied to CSCI to be registered. We talked to a member of staff who has worked at Lyons Gardens since it opened. She said “I love it here”. She told us that there have been changes in the months since Paul Gale has been managing the home, all for the better. Lyons Gardens DS0000063991.V353075.R01.S.doc Version 5.2 Page 23 She said Paul is willing to let staff take responsibility and “get on with things” and is very positive and supportive. She has taken on a ‘communication’ project, which she has three hours a week for. The project has started with making a collection of pictures of food which are being used to assist people to make choices about what they want to eat. Meetings are held about every four weeks, with different people each time, so that the people who visit Lyons Gardens can have a say in what happens at the home. The company has a quality assurance system in place which includes getting the views of people who use the service. Visits to the home are carried out by a representative of the company and a copy of the reports are sent to CSCI. One of the people who has lived at Lyons Gardens for a long time told us that during the week following the inspection she and another service user would be interviewing the people who have applied to support them when they move into their new house. A record of tests of the fire alarms and emergency lighting is kept in each bungalow and showed us that tests have been carried out as required. We also saw certificates to show that the systems are checked regularly by an outside contractor. Fire drills are held each week in both bungalows: staff and people staying at the home are expected to evacuate the building as they would if there were a fire. A drill took place as planned during the evening of the inspection and everyone evacuated successfully. It was clear that staff and people using the service knew what to do. We found no health and safety issues to give us any concern. Lyons Gardens DS0000063991.V353075.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 2 2 3 3 X 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 3 3 X 3 3 X Lyons Gardens DS0000063991.V353075.R01.S.doc Version 5.2 Page 25 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 Standard YA1 Regulation 4 Requirement The home must work within its statement of purpose so that everyone is clear about the service that is offered. Each person who uses the service must agree a contract/statement of terms and conditions with the home. All staff must receive training in Safeguarding Adults as soon as possible after they start working at the home, as part of their induction. The stained carpet must be cleaned or replaced. Evidence must be available to show that all people working at the home have undergone all the required checks prior to employment, to make sure people who use the service are safe. Timescale for action 31/12/07 2 YA5 5 31/03/08 3 YA23 13(6) 31/12/07 4 5 YA24 YA34 23(2)(d) 19 and schedule 2 31/03/08 30/11/07 Lyons Gardens DS0000063991.V353075.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. Refer to Standard Good Practice Recommendations Lyons Gardens DS0000063991.V353075.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Cambridgeshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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. 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