Inspection on 18/12/06 for The Leys

This inspection was carried out on 18th 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Leys 02/10/08

The Leys 06/09/07

The Leys 14/10/05

The Leys 09/05/05

The Leys 28/02/05

The Leys 19/08/03

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

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

CARE HOME ADULTS 18-65 The Leys Park Lane Sharnbrook Bedfordshire MK44 1LX Lead Inspector Katrina Derbyshire Unannounced Inspection 18th December 2006 11:50 The Leys DS0000014926.V321242.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 Leys DS0000014926.V321242.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 Leys DS0000014926.V321242.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Leys Address Park Lane Sharnbrook Bedfordshire MK44 1LX 01234 781982 T/F 01234 781982 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) Lansdowne Care Services Mr D A Diemer Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places The Leys DS0000014926.V321242.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th October 2005 Brief Description of the Service: The Leys is a large six-bedded bungalow and self contained two-bedroom flat set in countryside on the outskirts of Sharnbrook. The home can provide residential care to eight adults with learning disabilities including those with physical disabilities. The home is staffed over a twentyfour hour period and is adjacent to a day care facility. All accommodation is on one level and there is ramped access to the buildings. Sharnbrook is about fifteen minutes drive from both Rushden and Bedford and there is a bus service to both towns. The service has its own transport, which assists service users in accessing facilities in both the village and nearby towns. The fees for this home vary from £1,050.00 to £1,782.67 per week. The Leys DS0000014926.V321242.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this visit was to undertake a key inspection. This unannounced visit took place on 18th December 2006. The manager David Diemer was present for most of the time. During the visit some of the communal areas were visited and the inspector spent time with many of the residents’ in the main dining area of the home. The care of two residents’ was examined by looking at their records and interviewing the residents’ and staff who look after them. The views of residents were also received and their feedback has been used alongside information from the home through a pre inspection questionnaire to assess the outcomes within each standard. Evidence used and judgements made within the main body of the report include information from this visit. Observations of care practice and communication between the residents’ and staff was also made at this visit. The focus of this inspection was to look at the key standards and to follow up on previous requirements. What the service does well: Residents feel that the amount of support that staff gives them in pursuing their leisure activities are good. One resident said “ they take me to a club that l like to go to” this was to explain that they could not attend if the staff did not help them. Other resident’s spoke of going to the cinema, swimming and different day care services that they had access to. This means that residents benefit from a varied amount of social and educational programmes to meet their individual needs. The home is also very careful when they employ new staff that they make sure that they check where they last worked and carry out another check against a special register that helps them make a decision if that person is suitable to work with vulnerable people. This means that residents can feel safe knowing that the home is cautious about whom they employ in the home and that they do take their responsibilities in the recruitment of staff seriously. The home is also good at the way they order and give out medication to the residents. They are very careful about making sure they order everything each resident need’s and then keep records of when they have given them out so everyone knows that it has been done. This is very good because it means all residents receive medication when they should to maintain their health. The Leys DS0000014926.V321242.R01.S.doc Version 5.2 Page 6 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 Leys DS0000014926.V321242.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Leys DS0000014926.V321242.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2&5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The assessment and pre admission arrangements at the home continue to be planned and are of a good standard, so that residents can make an informed decision on whether to move into the home. EVIDENCE: Each resident was noted to have an individual folder, which contained a variety of care records relating to him or her. Within one of the folders examined at this visit, documents were seen to be in place for a resident who had moved into the home since its last inspection. These showed that the resident had been given the opportunity to visit the home on several occasions before making a decision about moving into the home. Documentary evidence was also seen to indicate that the home had used all information available from a previous home to guide them in their own assessment of the residents needs. The assessment was comprehensive, and detailed the social and psychological needs of residents alongside their physical needs. The Leys DS0000014926.V321242.R01.S.doc Version 5.2 Page 9 The manager showed the work that the company was currently undertaking on revising the contracts of residency for residents at the home. The use of pictures will be used alongside words to assist the residents in understanding their rights and responsibilities; the example seen was also in colour. Contracts in place at this time need to detail the fees payable by residents and the cost of additional services, for example any contribution to transport costs. The Leys DS0000014926.V321242.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 support from staff to enable residents to make personal choices and decisions is good, so residents feel they are able to maintain an acceptable level of independence. EVIDENCE: The personal files of two resident’s were examined. These contained some clear and detailed information. Information was up to date, and the care plans adequately reflected the resident’s most up to date health care needs. It was also noted that where tasks or goals had been identified, that they had been broken down into measurable tasks with specific timescales. Evidence of resident/family/representative involvement was also seen. However within the care plan of one resident one entry had been made that stated that the resident ‘will wind up staff and residents’. A different description must be used to describe the possible impact of a residents’ behaviour/actions on others. The Leys DS0000014926.V321242.R01.S.doc Version 5.2 Page 11 Risk taking for residents’ continues to be discussed at the residents 6 monthly review meeting. New risks that are identified are considered with the resident and their family member or advocate, and this is then integrated into their plan of care. Documents that described varying activities undertaken by residents were seen. The activity had been described and it gave clear guidance on the required support needed for each resident, so that any risk associated with that activity would be reduced. Risk assessments were also in place on individual files examined relating to leaving the home unaccompanied, and the physical support required by the resident for example. Resident views from returned comment cards to the Commission for Social Care Inspection show that residents are satisfied with the level of decision making that they have at the home. One resident spoke of their continued choices that they had in the home and how staff supported them in maintaining their independence. Care records contained entries demonstrating that residents are able to maintain personal relationships of their choosing, information was in place to ensure staff at the home knew the support to be provided to assist the resident in doing so. As previously reported evidence was also seen to demonstrate the varying methods of communication staff used with the residents so that they could communicate their needs, wants and desires. Staff for example have received training in the use of makaton; pictorials are in use and continual use of non-verbal communication was observed at this visit. The use of advocacy services was also noted to be used to support a resident in maintaining an appropriate level of independence through personal choices and decisions, arrangements were in place for the residents advocate to meet them on a regular basis, thus providing assistance independent from the staff at the home. The Leys DS0000014926.V321242.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. Links with the community continue to be good they help to support and enrich residents’ social and educational opportunities. EVIDENCE: A choice of meals was available over the week; menus submitted by the home reflected a varied diet and staff informed the inspector that residents were involved in setting the menus in the home and on occasions assisted in the homes ‘ shopping’. The kitchen was seen to be clean and tidy. Residents through discussion and through feedback from returned comment cards confirmed that they were satisfied with the food at the home. One resident spoke of the contact with their family, they could visit family members at their own home. Documents seen within the individual care records of residents gave clear guidance to staff in how they should support the resident in maintaining these close relationships with the family members. The Leys DS0000014926.V321242.R01.S.doc Version 5.2 Page 13 On the day of this visit one resident was going to visit a family member, staff had arranged this and one member was driving the resident there using the homes own transport. Examination of a card sent to the home within the past month from the family of another resident said, “I wish to say how pleased we are with the kindness and care by the staff at The Leys”. Management advised that none of the resident’s were engaged in paid employment at this time. Residents through discussion spoke of their attendance at varying local day facilities and described their programme of learning. Information examined supported this as records were maintained to show that one resident for example had received help through a course on communicating through cooking. Entries made within the care records described the social and leisure activities the resident’s had received. Records viewed on the day of inspection indicated that activities that had been provided for example were shopping trips, walks and going out for a pub meal/drink. Another resident attended the sparkle club. The care records seen also identified very different individual interests of the residents and they were specific in the identification of the residents preferred leisure interests, regular contact with family members and visits to their homes were also included. Residents spoke of their favourite things that they liked to do and these included for one resident an interest in music; which they had access to in their room with audio equipment in place. Staff spoke of links with the local community and the home is known in the area enabling residents to participate in a variety of social and educational facilities. The home describes throughout its literature the importance of integration into community life; the residents who are able use local pubs, shops and parks on a regular basis and the home owns transport to assist in this. Residents also help with caring for the animals at the home, which include ponies, goats and chickens. The Leys DS0000014926.V321242.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. Personal support is offered in the home in such a way to protect and promote resident’s privacy. EVIDENCE: There was documentary evidence that the home accessed outside healthcare professionals and services as required; in order to meet the healthcare needs of resident’s. The home is supported by a variety of health and medical advisors through a local clinical resource centre. Medical visits were being recorded separately to daily notes, and a variety of healthcare monitoring charts were in use. Two of the resident’s spoken with confirmed that they were able to see their General Practitioner when needed, staff would arrange the appointment for them and in addition provide transport to the local surgery. The home was supporting a number of residents with specific health care issues and/or a sensory impairment. One resident had recently undergone some health tests. However it was noted that a health assessment of residents had not been undertaken. The home now needs to seek initiating a Health The Leys DS0000014926.V321242.R01.S.doc Version 5.2 Page 15 Action Plan for all residents, with the appropriate healthcare professionals in accordance with the guidance from the Valuing People White paper 2001. Medication stocks were examined. Medication administration records had been signed and gave clear information on the medication to be given and the times that this should be done. The manager advised that one staff member has overall responsibility for ordering the supplies of medicines for the residents at the home. Medication was seen to be stored in a locked cupboard. Training records submitted by the home showed that all staff designated to administer medication had received training in this area. Within the care records examined specific entries had been made to guide and direct staff in how resident’s wished to receive personal care. One entry indicated a specific request by a resident on how staff should ensure that their privacy was maintained, when having a bath. Staff through discussion demonstrated an awareness of this and confirmed that this guidance was followed. Observation at this visit of the support offered to one resident when they required assistance, showed staff to communicate with them in an appropriate manner. The Leys DS0000014926.V321242.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. Referrals under the local protection of vulnerable adults scheme must be made to ensure residents benefit from a multi disciplinary agency approach. EVIDENCE: The homes complaints procedure was noted to give guidance on how to complain, to whom and the timescale for response by the home. One complaint had been received since the homes last inspection. Documentary evidence was seen that showed that the home had responded to the complainant. Social services had also looked into the concerns raised and a copy of their findings were also seen at the home. The manager informed the inspector that this complaint remained unresolved, and that it was with the senior management of the company. Feedback from residents through comment cards sent to the Commission for Social Care Inspection showed that residents were aware of their right to complain to the home. The home has in place the local policy for the protection of vulnerable adults. Training records submitted to the Commission for Social Care Inspection by the home show staff have received training in this area. However entries seen within the care records examined described two separate incidences between residents. One dated 14/12/06 on a contact sheet, described one resident The Leys DS0000014926.V321242.R01.S.doc Version 5.2 Page 17 raising their voice at another and then that the resident “hit them on the arm”. No incident report had been completed or referral under the Protection of Vulnerable Adults Scheme, or information on how the resident was supported following this incident. The owner of the home made contact with the Commission for Social Care Inspection following this visit, on 19th December 2006. He advised that the home had now contacted Social services, who had advised them that they did not require a referral of this nature under the scheme. In view of the decision and feedback from Social Services to the home regarding this specific incident and their view that no follow up was required, the quality outcome has been rated ‘good’. This is based on the home ensuring that staff had received training in this area and having in place a homes policy. However the home must still work to the procedures set out in the local multi agency protocol for the Protection of Vulnerable Adults (POVA). The decision on how to proceed when there is suspected abuse of a vulnerable adult must follow the guidance within the above protocol. In doing so once the home has made the referral the decision on how to proceed is undertaken by the coordinating agency, not the home, as set out within the guidance. The Leys DS0000014926.V321242.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. Furnishings and fittings are domestic and of a good standard and help to provide a homely environment for the residents to live in. EVIDENCE: All accommodation is provided on the ground floor with easy access to all buildings for the residents. The home is situated just outside of the village of Sharnbrook in a rural setting. There is a large amount of outdoor space available to the residents and this is well kept. Up to six residents can share a lounge and dining room in the main building, at the time of this visit five residents were living in this part of the home; two other residents share a twobedded bungalow providing its own self-contained accommodation. Some areas had been redecorated since the homes last inspection. The main lounge had been repainted, new carpeting had been fitted and the removal of a The Leys DS0000014926.V321242.R01.S.doc Version 5.2 Page 19 fixed television cabinet had been undertaken. In addition a new bath had been fitted. One resident showed the inspector their individual room. This contained numerous items that helped in creating a homely and personal space for the resident. The resident indicated that they were happy with their room, which contained photographs, pictures, television, music equipment and ornaments. All the areas seen at this visit were noted to be clean and tidy. The Leys DS0000014926.V321242.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The systematic approach and systems in place for the training of staff ensure residents are supported by a staff team equipped with the knowledge to provide care to meet their needs. EVIDENCE: Training and development plans for staff were submitted by the home to the Commission for Social Care Inspection. These included mandatory and specialist training courses, and included LDAF (Learning Disability Award Framework) induction training, medication training, and NVQs. Staff also confirmed that training was always available and that this had been the case throughout their employment with the home. Information supplied shows that 84.6 of staff holds a National Vocational Qualification in Care at level 2 or above. A check of staff files was undertaken to look at recruitment practices. It was noted that the files contained proof of identity, references and that Criminal The Leys DS0000014926.V321242.R01.S.doc Version 5.2 Page 21 Records Bureau clearance had been obtained prior to commencement of employment. Records examined showed that supervision of staff was being undertaken in accordance with the National Minimum Standards. Staff through discussion confirmed this. Staff demonstrated genuine friendliness towards residents, and provided support in a respectful and sociable manner. As a consequence, a relaxed atmosphere was noted in the home. However when all residents had returned home for the day, a change in the atmosphere was observed in the home specifically relating to the interaction between residents, one resident left the dining area, as they appeared to become nervous. This was discussed with the manager at this visit and has been addressed in the Concerns, Complaints and Protection section of this report. The Leys DS0000014926.V321242.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 good. This judgement has been made using available evidence including a visit to this service. Health and safety systems in this home are sufficient to provide an environment for residents that reduce the risks associated with this area. EVIDENCE: The manager has been in post for several years. Training records submitted by the home show that he has the Registered Managers Award and completed this in 2005. One staff member recently employed at the home said, “ I really enjoy working here its such a happy home, the residents are happy they really are”. Observation at this visit showed the manager interacting with both residents and staff, communication between them appeared relaxed and unhurried. The Leys DS0000014926.V321242.R01.S.doc Version 5.2 Page 23 The Commission for Social Care Inspection, as required by regulation 26 of the Care Homes Regulations 2001, has received providers’ reports, on a monthly basis. The home was noted to continue to carry out consultation with the residents in different forms. Staff as previously reported again confirmed that on a day-to-day basis residents are asked for their views and these decisions are then integrated into the care plans of the resident, examples included evening activities. More formal methods such as residents meetings had taken place in the past and minutes were available for inspection, but the home recognised that the views of all residents could not be sought in this way. Again as previously reported the homes management attended training in resident’s consultation and are working on ways to introduce new approaches of communicating through the use of photographs and then receiving the individual views of all the residents. The manager again confirmed that they would then use the views of the residents to change policies and the running of the home. In-house health and safety checks were taking place approximately as needed. Health and safety systems at the home were seen to be carried out in accordance with the guidance within the homes policy. The most recent fire and environmental health inspection reports show that the home had met the standards in these areas, with revised risk assessment relating to fire being undertaken. In addition cleaning products were seen to be locked away, risk assessments had been undertaken for areas and activities in the home. No other concerns relating to health and safety were noted during this inspection. The Leys DS0000014926.V321242.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 4 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X The Leys DS0000014926.V321242.R01.S.doc Version 5.2 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 12 & 15 Requirement Timescale for action 15/02/07 2. YA23 3. YA39 Care plans must not contain opinion based statements, but describe the possible impact of a residents actions on others in a non judgemental way. 12, 13 & The home must report all 18 suspected incidences of abuse in accordance with the local protocols for the Protection of Vulnerable Adults. 24(1)(2)(3) The home must show the results of resident’s views and how they have been used to influence the running of the home. (Previous timescale of 31/03/06 not met) 31/01/07 31/03/07 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. Refer to Standard YA5 Good Practice Recommendations Additional costs to residents should be included within their contract of residency, including details of the cost of DS0000014926.V321242.R01.S.doc Version 5.2 Page 26 The Leys 2. YA19 transport. The home should initiate with the relevant medical professionals for all residents to have a Health Action Plan in accordance with the Valuing People White Paper 2001. 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