Inspection on 12/12/06 for The Ley Community

This inspection was carried out on 12th December 2006.

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 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 Ley Community 28/02/06

The Ley Community 11/10/05

The Ley Community 14/03/05

The Ley Community 25/02/05

The Ley Community 26/03/04

Similar services:

Flint House

Yeldall Manor

Cherwood House Care Centre

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

CARE HOME ADULTS 18-65 The Ley Community Sandy Croft Sandy Lane Yarnton Oxfordshire OX5 1PB Lead Inspector Nancy Gates Unannounced Inspection 12th December 2006 & 9th February 2007 10:00 The Ley Community DS0000013104.V329839.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 Ley Community DS0000013104.V329839.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 Ley Community DS0000013104.V329839.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Ley Community Address Sandy Croft Sandy Lane Yarnton Oxfordshire OX5 1PB 01865 378600 01865 842238 enq@tey.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) The Ley Community Mr Paul Goodman Care Home 58 Category(ies) of Past or present alcohol dependence (58), Past or registration, with number present drug dependence (58) of places The Ley Community DS0000013104.V329839.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total number of persons that may be accommodated at any one time must not exceed 58 28th February 2006 Date of last inspection Brief Description of the Service: The Ley Community is a ‘therapeutic community’ situated within a village on the outskirts of Oxford, accommodating up to 58 people. The Community provides a structured and specialist programme for individuals to overcome drug and alcohol problems. This includes opportunities for change, re-building self-esteem and subsequently to move on to independent employment and accommodation. The accommodation comprises of three large residential units, set within large and exceptionally well-maintained grounds. An outdoor swimming pool and multi purpose sports pitch are available for recreational activities structured within the programme. Staffing is provided within guidance from the CSCI and uses peer support to manage the day to day running of each building. The current fee for this service is £421 per week. The Ley Community DS0000013104.V329839.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. From the 1st April 2006 the Commission for Social Care Inspection (CSCI) has developed the way it undertakes the inspection of care services. The inspection of the service was an unannounced ‘key inspection’. Two visits were conducted to the home one in December 2006 and one in February 2007. The total number of hours spent at the home was 10 hours. The time spent at the home allowed for a thorough look at how well the service is doing. The inspection took into account detailed information provided by the service manager inclusive of information that CSCI has received about the service since the last inspection. The inspector asked for the views of the people who use the service. The inspector also asked the views of others who support the needs of the people who use the service via a questionnaire that the CSCI sent out. Staff and residents were very welcoming. The inspector looked around the home including the bedrooms of the residents at their invitation. A number of records were viewed including a resident’s care plans, staff recruitment records, staffing rotas and maintenance records. The inspector looked at how well the service was meeting the standards set by the government. The report includes judgements about the standard of the service. What the service does well: The management and staff at The Ley Community continue to offer an exceptional range of experience and knowledge to support the rehabilitation needs of residents. The programme offered to residents continues to provide a structure that assists individuals throughout the rehabilitation process. The assessment and admission process places great emphasis on the commitment needed from potential residents to start the rehab process. The admissions team ensure that the maximum amount of information is available to support an admission decision. Residents’ individual plans reflect who they are, detail progress through the programme and are of a good standard. The Ley Community DS0000013104.V329839.R01.S.doc Version 5.2 Page 6 Whilst the programme has strict boundaries, residents have a clear understanding of the restrictions of the programme and the impact on decisions and independence. Risks are measured appropriately. Privacy, choices and freedoms are significantly restricted. Discussion with residents throughout the inspections continued to provide strong evidence that this is essential and underpins some of the success of the programme. “It’s been really hard at times, I kind of knew that things would be like this, but I found it difficult to accept that people would get to know absolutely everything, but that’s what makes it successful because you can’t hide anything…if you try to hide stuff people get to know and it messes everything up…it works though because it makes you think about how those relationships might influence what you do.” Clear descriptive accounts of ‘personal development’ are included within support plans. “This programme has saved my life, and helped me help others to save their lives…I’ve gained strong and solid friendships and supports…people can rely on me and me them…honesty and respect play a big part in my relationships now – they never did before…I am happy with the person I am, I actually like me, I don’t have to pretend to be somebody or something I’m not…The future belongs to me.” Plans demonstrated clear progression and achievement. An exceptional level of support and structure remains, balanced by the direction of the rehabilitation programme and the peer support. From the evidence seen, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. A good and consistent relationship has been continued with the wider community. No complaints have been received at the home since the last inspection. No information concerning complaints, concerns or allegations has been received by the Commission since the last inspection. A clear and robust complaints process is available to residents and their representatives. Complaints are managed efficiently and within appropriate timescales. Protection of residents is assured by the availability and knowledge of the local adult protection guidance. Residents expressed positive views of the accommodation offered, “It’s one hundred times better than what I’m used to”. Clear pride through being part of cleaning and maintenance “crews” ensure that all accommodation is cleaned and maintained to a high standard. The Ley Community DS0000013104.V329839.R01.S.doc Version 5.2 Page 7 Tours of the premises with residents demonstrated their continued commitment to cleaning the environment to a high standard, clearly demonstrating the requirements of participation. ‘Inspection teams’ check quality on a daily basis. Staff are competent in supporting the needs of residents. Robust recruitment procedures ensure, as far as possible, the protection of residents. Skills are supported by comprehensive training opportunities. The management structure at The Community led by the Chief Executive, Programme Director, Assistant Programme Director allows for the community to continue to operate with transparency and integrity. Administrative support staff underpin the integrity and operation of the community to an excellent standard. 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. The Ley Community DS0000013104.V329839.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 Ley Community DS0000013104.V329839.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 excellent. This judgement has been made using available evidence including a visit to this service. Clear assessment and the admission documentation allow for a robust admission process. EVIDENCE: Two full time admissions staff support potential residents through the admissions process, providing clear information regarding the programme and the commitment required. Admissions staff have a responsibility to ensure that detailed information is gathered to assist management staff to make an informed judgement as to whether a resident is suitable for admission. Residents confirmed that self-referral starts the process; self-assessments, an interview and observational assessments are undertaken before and throughout the admission process. It is clear that commitment to the programme from potential residents must be established before admission. Funding confirmation in addition to admission documentation has to be in place before an admission decision can be made. The Ley Community DS0000013104.V329839.R01.S.doc Version 5.2 Page 10 Decisions for admission continue to be made within a management meeting, an opportunity for presentation of assessment information including legal, funding and detoxification issues, demonstrating clear reflective practice. The current fee for this service is £421 per week. The Ley Community DS0000013104.V329839.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 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ individual plans reflect who they are, detail progress through the programme and are of a good standard. Residents have a clear understanding of the restrictions of the programme and the impact on decisions and independence. Risks are measured appropriately. EVIDENCE: Residents’ plans detail the structure and key stages of the programme. Individuals are expected to complete the plans within the ‘key stages’, describing achievement and further areas for development. Beliefs, attitudes and behaviours are clearly recorded to assist the assessment of where people are in the programme. A strong theme within the key stages are self-examination, explanation of feelings and behaviours, this provides a clear progress report for individuals to The Ley Community DS0000013104.V329839.R01.S.doc Version 5.2 Page 12 reflect upon who they were at the beginning of the programme to where they have got to. Common themes relating to self-worth, influential relationships, criminal history, family relationships, chaotic lifestyles and very little respect for others allow for peer relationships to challenge and confront individual issues. The decision to enter The Community ultimately falls to the prospective resident following a stated and contractual understanding of the restrictive nature of the programme. The ‘terms and conditions of residence’, alongside the ‘ personal contact and visits information’ leave prospective residents in no doubt about how restrictive the initial stages of the programme are. Privacy, choices and freedoms are significantly restricted. Staff monitor incoming and outgoing mail and can withhold items that may be unsuitable or detrimental to ongoing rehabilitation. Staff are also present whilst telephone calls are occurring to again ensure that content of conversations is not detrimental to the individual’s progress within the programme. Contact/visits from family members/friends/partners are also restricted within the initial stages of the programme, “Whilst this is really hard you have to give yourself time to settle in and not talk to anyone who might make you think about leaving.” Discussion with residents throughout the inspections continued to provide strong evidence that restrictions are essential and underpin some of the success of the programme. “It’s been really hard at times, I kind of knew that things would be like this, but I found it difficult to accept that people would get to know absolutely everything, but that’s what makes it successful because you can’t hide anything…if you try to hide stuff people get to know and it messes everything up…it works though because it makes you think about how those relationships might influence what you do.” Progress through the programme to re-settlement allows for the strictness of the limitations to be lifted in an aim to start the process to independent living. Risk is determined within the remit of the programme at The Community. Occupational risk assessments i.e. use of the laundry, gardening equipment, use of the kitchen, are overseen by senior residents and if needed staff members. The admissions process determines if an individual would pose a risk to themselves or others. A risk management policy remains available within the community for reference and guidance. The Ley Community DS0000013104.V329839.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, 15, 16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. An exceptional level of support and structure remain, balanced by the direction of the rehabilitation programme and the peer support. Restrictions are clearly understood by residents before admission to the home. A good and consistent relationship has been continued with the wider community. EVIDENCE: Clear descriptive accounts of ‘personal development’ are included within support plans. “This programme has saved my life, and helped me help others to save their lives…I’ve gained strong and solid friendships and supports…people can rely on me and me them…honesty and respect play a big part in my relationships now – they never did before…I am happy with the The Ley Community DS0000013104.V329839.R01.S.doc Version 5.2 Page 14 person I am, I actually like me, I don’t have to pretend to be somebody or something I’m not…The future belongs to me.” Plans demonstrated clear progression and achievement. A Programme Liaison Co-ordinator (PLC) continues to be employed at The Ley Community to manage and oversee education and training for residents. Residents are encouraged and supported throughout the programme to access skills courses through a college network. Course subjects include English and numeracy facilitated by a local college tutor, potentially leading to a recognised qualification. The rehabilitation programme requires residents to take more responsibility for planning a future beyond The Ley Community, which includes finding full time employment; to produce a curriculum vitae (CV), to write letters of application and to undertake training in interview skills. A resident confirmed that future planning is an essential element of ‘moving your life on’. Voluntary employment opportunities are available with local businesses/groups. Opportunities include becoming a member of auxiliary staff at The Ley. Application and interview for the posts are undertaken. Leisure and recreational elements are closely linked to the structure of the programme; responsibility for the care of animals and birds is ‘built into’ the recognised stages. A recent invitation to assist Oxford University to monitor a badger population has given people the opportunity to feel valued, and respected A swimming pool and astro-turf pitch are available for recreation. Stage four of the programme provides the remit for residents to access the local community. Accessing the wider community at weekends is restricted although there are no ‘locked gates’ that prevent individuals from leaving. Maintaining good relationships with the wider community is facilitated within ‘open days’ and through the ‘liaison officer’. Family visits to service users are carefully facilitated and monitored. Restrictions are stated within terms and conditions/contracts. ‘Exclusive relationships’ are not permitted, clearly stated within the home’s brochure, which states “Experience has clearly demonstrated that exclusive relationships between residents damage both the programme and residents concerned”. Residents had a clear appreciation that the programme can be influenced significantly if a relationship develops. The Ley Community DS0000013104.V329839.R01.S.doc Version 5.2 Page 15 Residents are responsible for catering, including ordering of supplies and the preparation of meals. Comments regarding the standard of the food were positive. An expectation of the programme is for service users to dine together. Three meals a day are provided, plus supper. The Ley Community DS0000013104.V329839.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. 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 are appropriately supported to meet their health care needs. Medication is stored and administered appropriately. EVIDENCE: The programme requires a high level of personal responsibility for personal hygiene and the community; peer support ensures that levels are maintained. Female service users are supported within single sex groups to ensure their needs are being listened to. Topics for the women’s group include, Relationships with men, other women and children, Building up self confidence/self worth, Body image, Abuse (mental, physical, sexual, violence), Past issues, Criminality (theft and possessions – crack and prostitution), Family guilt, Leaving the programme. The Ley Community DS0000013104.V329839.R01.S.doc Version 5.2 Page 17 A GP can be accessed on a weekly basis within the home. All other primary health care needs can be met upon request. Dental treatment is available. Healthcare plans are written as required dependent on changing need. A monitored dosage system (blister packs) for medication administration is used alongside individualised boxes/bottles. Medication administration records are based upon a local pharmacy format. Medication administration records were generally accurate. Medication is stored appropriately. Staff receive training on an annual basis from a local pharmacist although competency for the administration of medication is not formally assessed. Consideration is being given to a number of staff receiving formal training with a view to assessing the competency of the remaining members of staff. The assistant programme director stated that a pharmacy inspection by the pharmacist who supplies the home is proposed for the near future. The inspector very much welcomes the audit/inspection by the pharmacist, although it is acknowledged that safe storage and administration are ongoing at the home. The Ley Community DS0000013104.V329839.R01.S.doc Version 5.2 Page 18 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. A clear and robust complaints process is available to residents and their representatives. Complaints are managed efficiently and within appropriate timescales. Protection of residents is assured by the availability and knowledge of the local adult protection guidance. EVIDENCE: No complaints have been received at the home since the last inspection. No information concerning complaints, concerns or allegations has been received by the Commission since the last inspection. Information regarding how to complain is available to all residents. Residents confirmed that they are happy to talk to someone if needed and are aware that an issue ‘can be taken further’. A clear and robust complaints procedure is available to both service users and their representatives. The home has a copy of the Oxfordshire multi agency guidance for the Protection of Vulnerable Adults. The Ley Community has produced policy documentation relating to the protection of vulnerable adults. The Ley Community DS0000013104.V329839.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. 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. A good standard of accommodation is provided for residents. The cleanliness of the accommodation is of an excellent standard. EVIDENCE: Accommodation provided remains at a good standard. Residents expressed positive views of the accommodation offered, “It’s one hundred times better than what I’m used to”. Clear pride through being part of cleaning and maintenance “crews” ensure that all accommodation is cleaned and maintained to a high standard. Shared rooms remain and are considered a very important element of the programme. All rooms viewed were exceptionally clean and tidy, an element of the programme that must be adhered to. The Ley Community DS0000013104.V329839.R01.S.doc Version 5.2 Page 20 Female residents ‘share’ rooms, privacy continues to be respected. Tours of the premises with residents demonstrated their continued commitment to cleaning the environment to a high standard, clearly demonstrating the requirements of participation. ‘Inspection teams’ check quality on a daily basis. The Ley Community DS0000013104.V329839.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff are competent in supporting the needs of residents. Skills are supported by comprehensive training opportunities. A clear and robust recruitment process ensures the protection of residents. EVIDENCE: Staff spoken with are clearly knowledgeable regarding the needs of people at The Ley Community, personal experiences often giving greater insight into the challenges of the programme. Residents expressed confidence in the skills and understanding of the staff team. Four staff files were viewed. Clear, consistent and up to date records are held reflecting the requirements of the standards and legislation. A photograph is included within staff files. The Ley Community DS0000013104.V329839.R01.S.doc Version 5.2 Page 22 The recruitment and employment of previous residents may highlight a number of issues within recruitment checks, but acknowledgement is made of a valuable experience and support that can be provided from people who have completed the programme. Staff confirmed that comprehensive training relating to the needs of residents is available. Core training including fire safety, health and safety, first aid, food hygiene, risk assessment and care planning and co-ordination for people with drug and alcohol problems is undertaken on a regular basis. Specialised training and a nationally recognised qualification are offered to all staff members clearly acknowledging the ongoing and changing needs of residents. The Ley Community DS0000013104.V329839.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The management structure allows for aims and objectives to be achieved by all community members whilst ensuring health and safety responsibilities are upheld. The quality of support offered to residents is monitored effectively. EVIDENCE: The management structure at The Community led by the Chief Executive, Programme Director, Assistant Programme Director allows for the community to continue to operate with transparency and integrity. Administrative support staff underpin the integrity and operation of The Community to an excellent standard. The Ley Community DS0000013104.V329839.R01.S.doc Version 5.2 Page 24 An annual report is produced at The Ley Community detailing the achievement of aims and objectives and the plans for the forthcoming year. Residents’ involvement has been noted within the quality reviews by funding providers, resulting in reports commending The Ley Community and the programme it provides. A trustee of The Community visits on a monthly basis completing a report, which assesses the support and services provided. Records viewed regarding health and safety were up to date. The Ley Community DS0000013104.V329839.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 X 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 4 33 X 34 4 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 4 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X X 4 3 X X 3 X The Ley Community DS0000013104.V329839.R01.S.doc Version 5.2 Page 26 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. 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. Refer to Standard Good Practice Recommendations The Ley Community DS0000013104.V329839.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 The Ley Community DS0000013104.V329839.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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