Inspection on 15/01/07 for Ryan Q.C. Homes, The Elms

This inspection was carried out on 15th January 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ryan Q.C. Homes, The Elms 14/01/08

Ryan Q.C. Homes, The Elms 16/02/06

Ryan Q.C. Homes, The Elms 26/09/05

Ryan Q.C. Homes, The Elms 30/12/04

Ryan Q.C. Homes, The Elms 17/05/04

Ryan Q.C. Homes, The Elms 15/03/04

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Applegarth

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Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Ryan Q.C. Homes, The Elms 10 Repton Court The Arbours Northampton Northants NN3 3RQ Lead Inspector Keith Charlton Unannounced Inspection 15th January 2007 02:20 Ryan Q.C. Homes, The Elms DS0000037246.V326970.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 Ryan Q.C. Homes, The Elms DS0000037246.V326970.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. Ryan Q.C. Homes, The Elms DS0000037246.V326970.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ryan Q.C. Homes, The Elms Address 10 Repton Court The Arbours Northampton Northants NN3 3RQ 01604 411858 01604 499720 laurierqch@aol.com 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) Mrs Margaret Laurie Duggan Mrs Margaret Laurie Duggan Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Ryan Q.C. Homes, The Elms DS0000037246.V326970.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. There is currently one Service User within the category of MD. By agreement there will not be any further admissions of Service Users under the age of 30 years. 16/2/06 Date of last inspection Brief Description of the Service: The Elms is one of two homes run by Ryan Q.C. Homes and provides personal care for up to three young adults who have learning disabilities. The home is situated in a cul-de-sac in a residential area of Northampton and is indistinguishable from neighbouring houses. The home is a bungalow with all bedrooms single occupancy. Fees are from £667 to £1538 per week – this information was on the Pre Inspection Questionnaire that the Registered Manager provided prior to the inspection. There are costs for extras – hairdressing, toiletries, holidays, some transport etc. Ryan Q.C. Homes, The Elms DS0000037246.V326970.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for residents and their views of the service provided… The primary method of inspection used was ‘case tracking’ which involved selecting two residents and tracking the care they received through looking at their records, discussion, where possible, with them and care staff and observation of care practices. This was an unannounced Inspection. The Registered Manager was on duty to assist with the inspection process. Other support staff also assisted. Planning for the inspection included looking at the last Inspection Report and assessing any notifications of significant events sent to the Commission for Social Care Inspection from the home. The Inspections took place between 14.20 and 15.50 on day one – this was terminated early due to residents going out for a birthday party - and completed the following day, and included a selected tour of the building, inspection of records and indirect observation of care practices. The Inspector spoke with two residents, two members of staff, a student on placement, a community tutor and the Registered Manager. There were 3 comment cards completed by residents with the assistance of their parents and these were very positive about living in the home. What the service does well: The service focuses on residents’ individual needs, e.g. residents spoken with said they liked living in the home and thought staff were friendly, that the food was good and they liked their bedrooms. Staff were found to be friendly in their dealings with residents. Care Plans are comprehensive and detailed to assist staff to deliver care that fits individual service users care needs. Pictures are beginning to be used for residents’ information, e.g. Care plans, and this is to be extended to other information - Quality Assurance Surveys, the Statement of Purpose that describes the services offered, the Complaints Procedure, etc., to make it easier for residents to understand this information. Bedrooms are personalised, homely and organised to residents’ styles of living with a large amount of possessions in them to make them homely. Ryan Q.C. Homes, The Elms DS0000037246.V326970.R01.S.doc Version 5.2 Page 6 Facilities are kept in a generally clean and tidy condition and decor is kept to a good standard. The Registered Manager arranges residents meetings to provide information about services and asks their views about them. The Registered Manager is generally thorough in planning for staff training and staff encouraged to complete National Vocational Qualification training so they can more effectively meet residents needs. Frequent staff meetings are held to alert staff to care needs and good staff practice. What has improved since the last inspection? What they could do better: That the frequency of outings is extended based on residents preferences, so as to provide more stimulation and interest. That a choice of foods is always provided to residents and recorded in food records and that there is more emphasis and encouragement for healthy eating. The garden needs to be kept in a tidy and presentable condition, for residents appreciation and so it does not adversely identify the home in the neighbourhood as run down. Staff supervision notes need to be kept as a reminder for staff as to good staff practice in providing care, training needs etc. The protection of residents’ welfare needs to be tightened by ensuring that all necessary staffing checks are in place – that there is a reference from the previous employer and that up to date Criminal Records Bureau checks are in place. Health and safety needs to be improved so that residents are protected from hot radiators, that fire doors are kept closed or held open by approved safety devices, and to ensure all staff know how to deal with challenging behaviour by receiving training in this important area of practice. Ryan Q.C. Homes, The Elms DS0000037246.V326970.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ryan Q.C. Homes, The Elms DS0000037246.V326970.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 Ryan Q.C. Homes, The Elms DS0000037246.V326970.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An assessment system to meet residents needs is in place. EVIDENCE: Residents said that they had visited the home before they made up their minds about going to live there. Evidence seen by the inspector showed that there are social work assessments prior to the admission of residents. Residents care arrangements are reviewed within a multi-agency framework on an annual basis, and care plans confirmed that an internal review takes place on a six monthly basis. Ryan Q.C. Homes, The Elms DS0000037246.V326970.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The individual needs and choices of people living in the home are generally well met. EVIDENCE: Residents spoken with thought they were well looked after and no one thought they were restricted, though there was mention of getting up and going to bed times by residents and staff, e.g. going to bed at 10pm as this is when the sleeping in staff starts the shift. The Registered Manager said she would talk to residents and make information more specific as to their daily living preferences of when residents would like to get up and go to bed. The inspector case tracked two care records, which clearly demonstrated that service users changing needs are being monitored and supported whilst living Ryan Q.C. Homes, The Elms DS0000037246.V326970.R01.S.doc Version 5.2 Page 11 at the home. Records, observations and discussions with residents demonstrated that they make decisions about their lives and have independent life styles, e.g. residents are encouraged to do household chores, do as much of their personal care as possible and they can use the kitchen with staff supervision and help with cooking, making drinks etc. Staff said service users can make decisions about their own lives wherever possible e.g. where they want to go on holiday, when they want to bathe, etc. They are asked their views on important issues in their meetings and these are recorded regarding food, holidays, outings etc. The Registered Manager and staff said that residents independence is always encouraged, as it is an essential part of the philosophy of the home. To increase residents participation in the running of the home, it was recommended that residents have representation in staff meetings and for staff interviews, if they wish. The Registered Manager said she would think how this could be operated in practice. Two residents’ care plans were viewed within individual record files. Residents said that they knew there was a care plan and they liked the pictures used to help them understand what it meant. Both files contained detailed and comprehensive information with actions stated as to how staff were expected to meet those identified needs. Residents life histories were also recorded, so that staff can appreciate all relevant issues relating to the resident. Evidence was seen of a range of risk assessments, which addressed activities chosen by residents that may present risk. Risk assessments identified aspects of each resident’s care needs that resulted in increased vulnerability. Staff spoken with were knowledgeable about the care and support that service users required. Residents commented that there are many occasions where they are able to make choices around their daily living. They feel involved in decision making within the home and able to make suggestions. Residents made reference to a range of structured daily activities they have undertaken and this was supported by a weekly plan of activities in their Care Plans. Two residents attend college at present. Ryan Q.C. Homes, The Elms DS0000037246.V326970.R01.S.doc Version 5.2 Page 12 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. Residents living at the home have the opportunity to have a fulfilling lifestyle. EVIDENCE: Ryan Q.C. Homes, The Elms DS0000037246.V326970.R01.S.doc Version 5.2 Page 13 The Residents spoken with said they could do what they wanted to do in the home and that they liked going out. Residents said they go on holidays and stay with their parents. There was also interest in having more frequent outings to the cinema, swimming, meals out, pubs etc. There was also no mention of local groups such as going to the local Gateway club. The Registered Manager said that these ideas would be followed up. Records showed that residents have been on trips and are asked where they want to go on holiday. Residents Meeting notes showed that they have been consulted and trips are planned in the future. Staff said that residents use a range of community facilities including local shops, pubs, the park, and the post office to get their money etc. On the afternoon of the inspection residents went out for a surprise birthday party, which they were pleased to go to. There is another Ryan QC home nearby and residents from that home have day care sessions within this home. Residents did not comment this on though the Registered Manager was aware this could be an issue in the future and arrangements would then have to be changed if this arose. Residents said they could have their visitors to the home and that there were no restrictions on visiting times. A staff member said that it was important for residents to maintain contact with their friends and family. The student on placement and the community tutor said that staff were always welcoming and that the care provided to residents was always of a high standard. Both residents said they liked the food. One resident showed the inspector a list of food in her Care Plan that she did not like, and said staff went along with this. Food records showed that residents were given an alternative if they wanted. These did not include many instances of vegetables being served. The Registered Manager said that this was an oversight and vegetables served would be recorded in the future. There are weekly planning meetings as to what food residents want for the next week and residents can go shopping with staff if they choose. There was a discussion with the Registered Manager as to how to increase the healthy content of meals and to discuss this with a dietician. The Registered Manager said the community tutor was going through this with residents in her sessions. Ryan Q.C. Homes, The Elms DS0000037246.V326970.R01.S.doc Version 5.2 Page 14 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 good. This judgement has been made using available evidence including a visit to this service. Residents receive good personal support with their physical health needs being met. EVIDENCE: Residents said that if they do not feel well then staff make sure that they can see the doctor. There is comprehensive information kept in Care Plans which details all medical appointments and check ups on an individual basis - GP, dentist, etc. Selected accident/incident Records were checked and it was found that staff had reacted appropriately to all situations presented. Staff stated that the pharmacist has trained all staff that issue medication. Staff training records supported this. The home has a policy and procedure for the safe administration of medications, which is kept at the beginning of the medication records for easy access for staff. Ryan Q.C. Homes, The Elms DS0000037246.V326970.R01.S.doc Version 5.2 Page 15 Medication records were checked and found to be up to date. Medication is kept securely locked away. Ryan Q.C. Homes, The Elms DS0000037246.V326970.R01.S.doc Version 5.2 Page 16 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 good. This judgement has been made using available evidence including a visit to this service. Residents views are listened to and acted upon. Staff are aware of the Vulnerable Adults procedure so as to ensure the protection of residents. EVIDENCE: Residents said that if they were worried about anything they would speak to staff or the manager and they thought it would be followed up. The Registered Manager stated in the Pre Inspection Questionnaire, that was provided prior to the inspection, that there have been no complaints made by residents or relatives in the last year. The Complaints Procedure is generally satisfactory but states that complaints need to be made in writing. However not all residents can write, and there was no explanation as to the role of the Commission for Social Care Inspection. The Registered Manager said the procedure would be altered to reflect these issues, as well as providing pictorial representation of the procedure to make it more understandable to residents. The procedure reflected the National Minimum Standard in that it stated that any complaints would be properly followed up. Ryan Q.C. Homes, The Elms DS0000037246.V326970.R01.S.doc Version 5.2 Page 17 There are residents meetings held where all residents are invited to attend and share their views about the home. A record of these meetings is available for residents and staff to refer to. Staff members on duty were asked about their understanding of whistle blowing procedures, and both demonstrated a good understanding of the protection of residents from abuse. The Registered Manager said training is provided to staff on adult protection. Ryan Q.C. Homes, The Elms DS0000037246.V326970.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a homely and comfortable environment, and standards of hygiene are good. The garden needs to be better maintained to provide a space, which is pleasant and usable. EVIDENCE: Residents said that they liked their bedrooms and they could have all their things in them. Some residents showed the inspector their bedrooms. Observations of the bedrooms demonstrated that décor in their bedrooms suit their lifestyles. Communal areas looked comfortable. Standards of cleanliness and odour control in all areas of the home were good. Ryan Q.C. Homes, The Elms DS0000037246.V326970.R01.S.doc Version 5.2 Page 19 The garden looked unkept on day one of the inspection in that grass was fairly long and needed cutting, chairs were upended, there was a burnt patch in the lawn and there was a ladder lying on the ground. The Registered Manager said this would be attended to though there had been high winds recently; hence garden chairs being blown over. Ryan Q.C. Homes, The Elms DS0000037246.V326970.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): 32,34,35,36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from a generally well trained staff group, with sufficient staff numbers on duty to meet residents needs. Staff checks need to be tightened to ensure there are up to date Protection of Vulnerable Adults checks in place. EVIDENCE: Ryan Q.C. Homes, The Elms DS0000037246.V326970.R01.S.doc Version 5.2 Page 21 Residents spoken to were very happy with staff and saw them as helpful and friendly. Staffing levels during the course of the inspection met the relevant minimum standards. There are two to three staff on duty during daytime periods, when other service users and staff from the other home are present, with a sleeping staff member on duty at night with staff on call if needed. There are shifts with one staff on duty with three or less residents in the home. Staff records were inspected. This was generally found to have all the necessary statutory checks, though there was an issue with one file in that a staff member had commenced employment with an out of date Criminal Records Bureau check. This had since been rectified. Identification was missing on one record; the Registered Manager said she would obtain copies of such documents to ensure they are all in files. The Registered Manager contacted the inspector to state that identification records had since been found in the home. Staff members spoken to had a good knowledge of service uses care needs. Records testified that they are supplied with regular supervision, though recording of the content was minimal, only stating that supervision had taken place. The Registered Manager said this would be followed up so that there would be a good record of performance etc regarding staff meeting residents needs. The Registered Manager has stated that there are approximately 75 of staff with a National Vocational Qualification level 2 qualifications or above, and that four staff were currently working on the National Vocational Qualification level 4 in Management, which is a high ratio of staff undertaking this training and is commended. Staff spoken to said they were encouraged by the Registered Manager to undertake this training. Staff records evidenced training in a wide range of topics – Epilepsy, Fire, Food Hygiene, First Aid, Health and Safety, Risk Assessment, Moving and Handling, Medication, Challenging Behaviour, Vulnerable Adults procedure, etc. Not all staff had received training on dealing with the challenging behaviour of residents – the Registered Manager said that this was being planned for early this year. Training records are kept within individual staff files. New staff have to go through a detailed induction programme, based on the Skills for Care professional model. The Registered Manager said that a training matrix has been set up to quickly identify who needs training in what topic, which was subsequently sent to the Commission for Social Care Inspection. Ryan Q.C. Homes, The Elms DS0000037246.V326970.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): 37,39,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents Health and Safety needs are not fully met by the management systems in the home. EVIDENCE: Ryan Q.C. Homes, The Elms DS0000037246.V326970.R01.S.doc Version 5.2 Page 23 Both residents and staff spoke highly of how the Registered Manager runs the home. The Staff Meeting notes seen are detailed and comprehensive and contain information as to how staff meet residents care needs. The Registered Manager said that the Quality Assurance survey had been lost on the computer and she was to reintroduce this. The Registered Manager then needs to analyse the results of surveys, produce an Action Plan and include this information in the Statement of Purpose. A staff member was asked as to the fire procedure and was aware of this. Fire records showed that testing of fire bells was taking place though not always on the required weekly schedule. Emergency lighting testing was in place and there are regular fire drills. A fire risk assessment is in place though fire doors were propped open around the home. The Registered Manager said that the Fire Officer had agreed this was satisfactory providing they were closed at night; however there was no evidence of this on file. The Registered Manager agreed to ensure fire doors were kept closed until contact with the Fire Officer and ask this advice to be put into writing or, failing this, for doors to be kept closed or approved devices to be installed to be able to shut in case of fire. Residents monies records were checked. They had receipts, running balances and two signatures. The hot water temperature was measured and found to be within the National Minimum Standard at 39c. As the National Minimum Standard is 43c, water can be hotter than this if residents wish so they can have a warmer bath. Health and Safety Policies and Procedures are in place and staff said they are encouraged to read them. There are Risk Assessments for safe working practices though radiators have not been risk assessed and there are no radiator covers. The Registered Manager said these would be fitted to ensure residents are protected from burns. A ladder was also on the ground in the back garden, which could have been a Health and Safety risk for anyone using the garden. The Registered Manager said this would be moved to a safe place. Ryan Q.C. Homes, The Elms DS0000037246.V326970.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 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 1 33 X 34 1 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 3 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 1 X Ryan Q.C. Homes, The Elms DS0000037246.V326970.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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 YA32 Regulation 18 Requirement All staff must be trained in appropriately dealing with challenging behaviour. Statutory staffing checks must be in place before staff commence employment. The Health and Safety systems in the home must protect the welfare of service users from harm. This includes protection from hot radiators and fire. Timescale for action 16/03/07 2. YA34 19 16/01/07 3. YA42 13 16/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA7 Good Practice Recommendations Care Plans need to show how residents have full choice in their lifestyles, e.g. rising and retiring times. Residents should be consulted as to the frequency they wish to have outings in the community, and then this to be DS0000037246.V326970.R01.S.doc Version 5.2 Page 26 YA12 Ryan Q.C. Homes, The Elms arranged. 3. 4. YA24 YA36 The garden needs to be kept in good order. Staff supervision needs to be recorded as to what were the issues discussed. Ryan Q.C. Homes, The Elms DS0000037246.V326970.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 Ryan Q.C. Homes, The Elms DS0000037246.V326970.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!