Inspection on 15/08/06 for The Lawns, Exmouth

This inspection was carried out on 15th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Lawns, Exmouth 10/10/05

The Lawns, Exmouth 24/05/05

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 The Lawns, Exmouth 52 Salterton Road Exmouth Devon EX8 2EJ Lead Inspector Belinda Heginworth Key Unannounced Inspection 15th August 2006 09:00 The Lawns, Exmouth DS0000062003.V295957.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 The Lawns, Exmouth DS0000062003.V295957.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. The Lawns, Exmouth DS0000062003.V295957.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Lawns, Exmouth Address 52 Salterton Road Exmouth Devon EX8 2EJ 01823 331712 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) Voyage Ltd Barbara Elizabeth Greenslade Care Home 10 Category(ies) of Learning disability (10), Physical disability (10) registration, with number of places The Lawns, Exmouth DS0000062003.V295957.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The manager must obtain the Registered Manager’s Award by November 2006 10th October 2005 Date of last inspection Brief Description of the Service: The Lawns provides personal and supportive care for 10 residents with learning and physical disabilities. The house is a detached three storey building in a residential area of Exmouth. All bedrooms are single with en-suite facilities. There is a large lounge, dining room and kitchen. Additional communal rooms are provided for games and relaxation. There are pleasant secure gardens to the front and rear of the property including level patio areas. The home has been adapted to meet the needs of residents with physical disabilities. The providers, Voyage Ltd are a large organisation with a number of registered homes throughout the region. Fees range from £1350 to £1650 per week. Additional charges are made to service users for the use of the home’s transport at a cost of £50 per month. The Service User Guide states that CSCI reports are available upon request to the manager. The Lawns, Exmouth DS0000062003.V295957.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 6.20 hours with the manager being present throughout. The people living at the Lawns have extremely limited verbal communication skills. They were therefore unable to contribute verbally to the inspection process. Significant time was spent with service users and observations were made during the inspection. Prior to the inspection the manager completes a questionnaire, which provides information about service users, staffing, fees and confirms that necessary policies and procedures are in place. Surveys were sent to service users and staff prior to the inspection. Comment cards were also sent to professionals who are connected to the home and questionnaires were sent to relatives. Five service user surveys were returned, which were completed by relatives. Six relative questionnaires were received and telephone contact was made with one relative. Eight staff surveys were returned and two comment cards were received from professionals involved with the home. All comments received were very positive about the home and the services. The inspector looked around parts of the building and some records were inspected. What the service does well: The atmosphere is the home is bright, fun and cheerful. Staff were observed being kind, caring and respectful. Staff demonstrated an excellent understanding of service users’ needs and how to communicate with them effectively. This was observed throughout the inspection. A high level of staff ensures service users’ needs are met well and met safely. The environment is bright, homely and clean. Service users’ bedrooms are personalised to take into account their preferences, wishes and needs. The manager and staff team are constantly reviewing the services and coming up with ideas to develop and improve the services. The home is run well by the manager who has excellent standards and ensures the home is run in the best interests of service users. This is reflected in the high standards of care delivered by the staff team. The manager monitors the quality of care regularly and seeks the views of service users, relatives and outside professionals to ensure the home is being run in the best interests of service users. The Lawns, Exmouth DS0000062003.V295957.R01.S.doc Version 5.2 Page 6 The information provided to staff prior to admission is very good. Good care plans are formulated from this information and through observational assessments. These are regularly reviewed to ensure the information is relevant and continues to help staff to meet service users’ needs. Any risks associated with service users’ care or activities are assessed and clear action on how to reduce any risks is clearly recorded. Decisions made on behalf of service users are discussed and agreed with relatives, service users’ representatives and professionals to ensure these decisions are made in the best interests of service users. Service users social needs are met through a good variety of activities and leisure pursuits. Health needs are well met and monitored and a well balanced diet is provided to service users with some choices of meals being offered. Medication practices ensure service users’ welfare is protected. Service users are protected from potential abuse through good staff training, staff having a good understanding of procedures, good management of service users’ finances and robust recruitment practices. What has improved since the last inspection? What they could do better: Suitable locks should be found and fitted to bedroom and en-suite doors to ensure service users, who can, gain access independently. There should be safe methods found to prevent the locking of communal toilets. This would enable service users to gain access safely. The Lawns, Exmouth DS0000062003.V295957.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 Lawns, Exmouth DS0000062003.V295957.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 The Lawns, Exmouth DS0000062003.V295957.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service The manager gathers enough information to ensure the home is able to meet service users’ needs prior to admission and provides good information prior to admission. EVIDENCE: Each service users’ file had a copy of the home’s Service User Guide, which provides service users with information about the home. Due to service users’ communication difficulties the manager intends to obtain this information on audiotape. Detailed assessments were carried out prior to admission. Staff visited service users on a number of occasions prior to admission to ensure a full assessment was completed and they were confident the home could meet the service users’ needs. The home also completes transitional work by arranging visits and short stays before service users move in fully. Relatives confirmed they were involved in the admission process and had received good information about the home. Carers confirmed that there was good information about service users to help them understand their needs. The Lawns, Exmouth DS0000062003.V295957.R01.S.doc Version 5.2 Page 10 Each service user is provided with Terms and Conditions of occupancy. This ensures that service users or their representatives know what services will be provided within the fee structure. The Lawns, Exmouth DS0000062003.V295957.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 at least once during a 12 month period. 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. Staff are provided with excellent information to meet service users’ needs and goals safely and consistently. EVIDENCE: Each service user has a plan of care and recorded information about their needs. There is detailed action for staff to follow to ensure each need / goal is met and monitored. Each service user has a key worker, who is responsible for co-ordinating all aspects of their care and completing monthly reviews of the care plans. Staff demonstrated an excellent knowledge and understanding of each service users’ needs. They were observed communicating with service users appropriately and being kind and respectful. A daily monitoring sheet has recently been introduced, where staff record the days events. The sheet is divided into sections for each shift covering - times service users chose to get up and go to bed, what they ate and whether a choice was offered, activities, daily living skills, interactions with others, The Lawns, Exmouth DS0000062003.V295957.R01.S.doc Version 5.2 Page 12 methods of communication used, contact with relatives, appointments and other comments. The daily records did not always reflect if care plan goals had been met. However, care plan goals tended to concentrate on general care and did not include day-to-day goals, particularly goals relating to independent living skills. Despite this, the information within care plans is excellent and the manager intends to review how care plans are written and used. Staff said they found the monitoring sheets much more useful and made reviewing the care easier. Relatives and a care manager confirmed that regular care plan reviews take place, which they intend. Relatives and care managers spoke highly of the staff team and felt the services provided were “excellent”. All decisions made on behalf of service users are agreed and discussed with relatives and care managers, particularly those that may infringe upon service users’ freedom of movement or privacy. Good records of such decision-making processes are recorded and reviewed regularly. The manager has also taken such issues to a “Good Practice Committee”. This is a group of independent professionals who advise on best practices where there might be an infringement on someone’s rights, albeit in the best interests of service users’ safety. (see section 24-30) Any risks to service users through general health, needs or activities are assessed and clear action to reduce any risks are recorded. Staff demonstrated a good understanding of such risks and were able to describe what they should do to reduce them. There is a high level of staff training within the home that is arranged around service users’ needs, ensuring their needs are met appropriately. The Lawns, Exmouth DS0000062003.V295957.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 &16 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from accessing the local community and taking part in appropriate activities. Service users rights are respected at all times. Service users benefit from a varied diet. EVIDENCE: Service users’ care plans included information about what they enjoyed doing in relation to activities, for example one service user enjoys swimming. Daily monitoring sheets and staff confirmed this took place. Other activities include trips out to the pub, theatre, picnics, horse riding, walks, skittles and many more. The home also employs an art therapist to come in to the home twice a week. Some service users join events through other organisations such as “link up”, which are an advocacy service. Relatives spoken with on the day of the inspection said they felt the staff team were “very motivated” and felt activities and opportunities to go out were very good. The Lawns, Exmouth DS0000062003.V295957.R01.S.doc Version 5.2 Page 14 During the last inspection it was highlighted that the majority of activities were carried out during the day because the day shift for staff ended at 8.30pm. Although it was recognised that staff were flexible in that they would stay on longer for an organised event, there was little opportunity for ad hoc trips out in the evening. Since the last inspection the manager has trialled various shift patterns to ensure service users have the opportunity to go out in the evenings. Currently the shift pattern has been changed so that there are enough staff on duty until 9pm to enable service users to go out in the early evening should they wish to. The change of shift pattern has also enabled the staff to be flexible in the days they work; this in turn has meant service users’ needs are better met. Daily monitoring sheets recorded some evening activities and staff confirmed they took service users to some organised evening events. The manager was aware that there was still room for improvement and intends to monitor this closely. On the day of the inspection service users went out in the home’s transport, some service users were either returning from a visit home or were going. One service user went for a shopping trip to Exmouth and others were seen either watching TV, using the sensory room, listening to music or spending time with staff. Relatives spoken to on the day of the inspection confirmed that the home supported their relative to maintain regular contact and said the staff were excellent at keeping them informed of any changes or important information. Feedback received from other relatives also confirmed that staff were excellent in their communication to them and said they were very happy with the care their relative received. Menus demonstrated a varied and healthy diet is offered to service users. Service users are provided with a choice of breakfast and supper. However the main meals are set with only two days a week where it showed service users should be offered a choice. Staff explained that they were aware of service users likes and dislikes and would always offer an alternative should a service user indicate they did not want or like what was on offer. On the days where the menus indicate service users’ choice, some service users plan and shop for the food and where appropriate prepare and cook it. Currently some staff are completing Total Communication training. When completed they will be trained to train all the staff in the home. The staff also intend to have better systems for communicating pictorially with service users. For example, photographs are being taken of meals so that in the future pictorial menus will be displayed. This will provide service users with an advanced opportunity to indicate whether they want the meal or would rather choose an alternative. One set of relatives spoken with on the day of the inspection said their son appeared to be healthy and seemed happy with the food in the home. The Lawns, Exmouth DS0000062003.V295957.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users’ health needs are well met. Service users’ dignity and privacy is respected. EVIDENCE: Staff had a good knowledge of how service users preferred to receive personal care. Care plans provide staff with information on personal care and how much support is necessary. Staff were observed being respectful, fun and kind. It was clear through observations that service users have an excellent relationship with staff. Throughout the inspection there was laughter and fun. Feedback from relatives also confirmed the staff team were kind, helpful and polite. There are good records of service users’ health care needs and how they are monitored. There was good evidence that such monitoring takes place. Service users are supported by staff to attend medical appointments. Medication storage and administration records were accurate. All staff that administers medication have received appropriate training and their competencies are assessed by the manager informally to ensure they The Lawns, Exmouth DS0000062003.V295957.R01.S.doc Version 5.2 Page 16 understand the training they have received and remain safe to administer medication. The manager intends to formalise these assessments by keeping a record. The staff confirmed the manager monitors their performance in relation to medication. The Lawns, Exmouth DS0000062003.V295957.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 at least once during a 12 month period. 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. Relatives and service users are assured they are listened to and complaints are dealt with appropriately. Service users are fully protected from abuse. EVIDENCE: The home has received no complaints since the last inspection. The detailed complaint’s procedure is within the Service User Guide, which is provided to each service user. Relatives said they felt confident that any concerns or complaints would be dealt with efficiently and effectively. The staff team are in the process of improving the pictorial communication systems they have. An example is the complaint’s procedure, which will suit the communication needs of service users when pictures or symbols are used. All staff have received training on adult protection awareness. Staff demonstrated an excellent understanding of abuse issues and knew what to do if they suspected any. Staff were able to describe all types of abuse and also highlighted subtle forms of abuse. Service users’ finances are managed well and fully protect service users from potential financial abuse. All but two service users’ relatives are appointees, which means that benefits are paid directly to them. The home is provided with monies to spend on behalf of service users. Good records with receipts are kept. Voyage Ltd is appointee for the other two service users. Bank accounts are to be opened on service users’ behalf and will be operated by the manager The Lawns, Exmouth DS0000062003.V295957.R01.S.doc Version 5.2 Page 18 of the home. Bank statements will be available to inspect once these accounts are opened. The Lawns, Exmouth DS0000062003.V295957.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. 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 benefit from a clean and homely environment. Some improvements are needed to the accessibility of some areas in the home. EVIDENCE: The Lawns is homely and clean throughout. Service users’ bedrooms are individualised with favourite colours being used to decorate and furnishings to suit their needs. Furnishings, fittings and decoration throughout the home are a good standard. The garden area to the front and rear of the property is paved with seating and areas to “play”. For example a basketball net has recently been purchased. The home has a number of communal areas, including a sensory/ activity room. Some staff felt that more communal space would be an improvement. Many of the doors in the home are locked by a coded keypad. This includes some service users’ bedrooms, the downstairs communal toilet, and the kitchen, the front and side doors. This was discussed at length during the last inspection. Due to some complex needs and risks of some service users it could be unsafe to have some of the doors unlocked. The staff team want to ensure they meet their responsibilities under their duty of care by keeping The Lawns, Exmouth DS0000062003.V295957.R01.S.doc Version 5.2 Page 20 service users safe. However, the decision to carry out these “restrictive practices” had not been discussed and agreed within a multidisciplinary setting. Individual care plans; risk assessments or the home’s Statement of Purpose and Service User Guide did not reflect the reasons for any restrictions or who was involved in the decisions. Since the last inspection these issues have been discussed within a multi-disciplinary setting – “A Good Practice Committee”, the Committee consists of independent professionals who advise on such issues and look at what is in the best interests of service users. The home has also consulted with relatives and care managers. The locked toilet door has been kept unlocked at times for a trial period, this proved to be unsuccessful after a few weeks as it became unsafe for some service users and is now locked again. Through discussions with the manager, the reason for the toilet being locked again was not only about some service users being unsafe but also about the service users being occupied in a meaningful way and therefore having less opportunity to be “unsafe” in the toilet. The toilet is also used as storage for service users’ incontinent pads and a hoist. Bedroom doors remain locked due to some service users entering the rooms uninvited. The current locks do no suit most of the needs of the service users living at the home therefore service users are unable to gain access to their own rooms without the support of staff. Whilst some service users would always need complete support to enter their rooms, some, would not. All bedrooms have en-suite facilities, however most were kept locked. Staff said some service users would be unsafe if left in the en-suite unsupervised. On inspection it was found that many of the en-suites contained toiletries and electrical equipment, which made it unsafe for some service users. It was suggested that the use of a locked cabinet in service users en-suites might prevent the room being so unsafe. Service users are able to gain access to the kitchen under supervision. When no staff are in the kitchen the door remains locked. The manager hopes to change the policy of locking some doors and find suitable locking devices to enable service users to gain access to their rooms, en-suite facilities and communal toilets safely. The Lawns, Exmouth DS0000062003.V295957.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported by enough caring and trained staff to meet their needs. Service users are protected by robust recruitment procedures. EVIDENCE: The home provides a high level of staffing to ensure service users’ needs, including social needs are met. The manager aims to provide 7 carers during the day and early evening and two staff from 9pm until morning. It was clear through observations made that service users needs were being adequately met with this high staffing level. Relatives and care managers who provided feedback felt service users’ needs were being met safely and appropriately. Recruitment procedures fully protect service users from potential abuse. Appropriate checks are made prior to someone working in the home, in including police checks. Interviews are carried out in the home where potential staff are introduced to service users. This provides the manager with the opportunity to observe how service users interact with the staff. A structured Induction training is provided by the organisation and the manager to ensure new staff understand health & Safety issues and working The Lawns, Exmouth DS0000062003.V295957.R01.S.doc Version 5.2 Page 22 with people with a learning disability. The induction training is linked to the Learning Disability Award Framework (LDAF), this is a nationally recognised standards expected to be achieved by staff that work in this kind of setting. The LDAF framework also provides evidence towards NVQ qualifications. Information received by the CSCI prior to the inspection indicates that 33 of staff have obtained NVQ level 2 or above. This is below the expected level of 50 but more staff are expected to obtain or start the qualification soon. This will be looked at during future inspections. One staff member spoken with on the day of the inspection said he had received a very good induction and described what he had learnt and how it had helped him to meet service users’ needs safely. Another staff was being supervised while waiting for a CRB clearance. A POVA first check had been obtained before he started working in the home. This practice of supervision while waiting for the CRB clearance ensures service users are protected from potential abuse. Other staff spoken said they felt the level of training was good. Staff records showed a good level of mandatory health & safety training was provided. Training relating to service users’ needs was also provided. Many staff were being trained as trainers to cascade the information down to all staff, for example training in Total Communication. The Lawns, Exmouth DS0000062003.V295957.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is being run in the best interests of service users. There are excellent systems to review, develop and improve the home. Service users safety and welfare are well protected. EVIDENCE: The manager has many years of experience of managing care homes and working with people with a learning disability. She is in the process of completing the Registered Manager’s Award. Staff spoke very highly of the manager and said they felt well-supported and received clear direction and leadership. The manager and staff are very service user focused and ensure the home is run in the best interests and needs of service users. This was observed throughout the inspection and has been reflected throughout this report. Relatives, care managers and other The Lawns, Exmouth DS0000062003.V295957.R01.S.doc Version 5.2 Page 24 professionals provided positive feedback of the manager and the home in general. The manager has excellent systems in place to review and monitor the care delivered to service users. This includes service user reviews, health reviews, staff meetings, and supervision with staff, appropriate training, reviewing of policies and procedures to name but a few. Voyage Ltd also completes monthly inspection visits and quality audit reviews. The inspector was told that satisfaction questionnaires are sent to service users where appropriate, to relatives and outside stakeholders. Not all of the information has been collated or acted upon yet. The manager expects this work to be completed soon. The fire logbook was found to be up to date and accurate. Fire risk assessments and staff training were completed, therefore protecting service users safety and welfare. The CSCI obtains information prior to inspections. The information includes conformation that all necessary policies and procedures are in place and are up to date. These are not inspected on the day but the information is used to help form a judgement as to whether the home has the correct policies to keep service users and staff safe. In this instance policies and procedures were in place. These along with risk assessments are reviewed regularly and are up dated where necessary, to ensure they are appropriate and reduce risks to staff and service users. The Lawns, Exmouth DS0000062003.V295957.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 4 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 3 23 4 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 X 34 4 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 4 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 4 X 4 X 4 X X 3 X The Lawns, Exmouth DS0000062003.V295957.R01.S.doc Version 5.2 Page 26 N/A 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA24 Good Practice Recommendations There should be suitable locks and systems in place that enable service users to gain independent access to communal toilets, their bedrooms and en-suite facilities. The Lawns, Exmouth DS0000062003.V295957.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Exeter Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Lawns, Exmouth DS0000062003.V295957.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. 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