Inspection on 11/09/07 for The Limes

This inspection was carried out on 11th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Limes 27/07/08

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 The Limes 76 Church Road Longlevens Gloucester GL2 0AA Lead Inspector Mr Paul Chapman Key Unannounced Inspection 11th September 2007 09:00 The Limes DS0000069313.V348421.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 Limes DS0000069313.V348421.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 Limes DS0000069313.V348421.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Limes Address 76 Church Road Longlevens Gloucester GL2 0AA 01452 41003 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) Look Forward (Gloucestershire) Limited Mr Daniel Joseph Coleman Care Home 6 Category(ies) of Learning disability (6) registration, with number of places The Limes DS0000069313.V348421.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Learning disability (Code LD) The maximum number of service users who can be accommodated is 6. Date of last inspection First inspection Brief Description of the Service: The Limes is a residential home for up to 6 adults with learning disabilities. The home is a large detached building, situated approximately two miles from the centre of Gloucester. The home is close to local amenities and within easy access to public transport. Accommodation is provided over two floors, with communal areas on the ground floor and bedrooms on the second floor. There is a garden to the rear of the property that people make use of and there is a parking area to the front of the house. The home has a Statement of Purpose and Service User Guide. Fees for the home range from £1088.00 to £1534.00 per week. The Limes DS0000069313.V348421.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This site visit took place in September 2007. The registered manager was in attendance throughout the visit. The CSCI received a completed AQAA (Annual Quality Assurance Assessment) prior to the inspection. Completed surveys were received from the parents of the 3 people living at the home, 2 healthcare professionals and 1 doctor. Time was spent observing the care of people and their interactions with staff. All people living at the home were spoken to and people gave their permission to see their bedrooms. The care of 2 people was looked at in depth that included looking at their financial, medication and personal records. One member of staff was interviewed about the care they provide, and 4 staff completed surveys that were returned to the CSCI. Other records examined included staff files, health and safety information and quality assurance records. In between the site visit being completed and the report being written the registered manager has resigned from the home. The inspector spoke to the organisation’s managing director about this. They explained that they have completed their own audit of the home identifying a number of shortfalls. The inspector explained the shortfalls they had identified. Speaking to the managing director at the point of this report being published in draft format they have given their assurance that the majority of shortfalls had already been addressed. What the service does well: The manager and staff have completed detailed assessments for the 3 people living in the home. This has enabled them to create care plans to meet peoples day-to-day needs. Care plans provide staff with detailed information that allows them to meet people’s needs consistently. Concerns raised by people in/outside the home are taken seriously and addressed appropriately. The Limes DS0000069313.V348421.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Each person living in the home needs to have a residency agreement/contract. Reviews of care plans need to be completed consistently. The manager should monitor the detail of the information contained in the monthly reports. People living in the home should be empowered to make decisions about their lives and evidence of this should be available for inspection. Long-term goals should be identified for each of the people living in the home. Evidence of those goals being worked towards should then be available for inspection. People must be supported to take part in age, peer and culturally appropriate activities People must be supported to become part of the local community. The manager must ensure that people’s rights are respected and responsibilities in their daily lives. Medication administration must be managed effectively to ensure that people are not being put at unnecessary risks. All staff must receive training in safeguarding adults. All of the maintenance issues identified in the report must be addressed. All of the staff recruitment records must reviewed to ensure that they meet the criteria of the regulations. Please contact the provider for advice of actions taken in response to this The Limes DS0000069313.V348421.R01.S.doc Version 5.2 Page 7 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 Limes DS0000069313.V348421.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 Limes DS0000069313.V348421.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, 5 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Peoples needs have been thoroughly assessed by the manager of the home and enables the staff team to meet current needs. There are no contracts of residency which makes it difficult for people and their relatives/advocates to be clear about what they can expect from the service. EVIDENCE: The admissions for 2 of the 3 people living in the home were examined. The home has an admissions policy in place. The inspector spoke to the father of one of the people who said that they felt the admission process was very good. Staff from the home supported one person in their previous placement. Their knowledge of the person in this previous placement has been included as part of the assessment process. One person’s file contained a copy of a recent community care assessment completed by their social worker, but the The Limes DS0000069313.V348421.R01.S.doc Version 5.2 Page 10 inspector was unable to find a copy of a similar assessment in the other person’s file. The manager must ensure that this is addressed with a copy of the assessment obtained from the person’s funding authority. This becomes a requirement of this inspection report. The assessments completed by the manager of the home are thorough and identify people’s needs. Feedback from relatives and other professionals confirm that people’s needs are being met at present. People are able to visit the home before they move in. The home is currently completing a fazed admission with one person where they are spending sometime at the home, and sometime with their family. This appeared to be working really well. Speaking with the person’s father they were very positive about the process. None of the people living in the home at present have residency agreements that identify what they can expect from the service. This was brought to the attention of the manager who gave their commitment to address this. This becomes a requirement of this inspection report. The Limes DS0000069313.V348421.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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People have care plans in place that enable staff to meet their day-to-day needs. Reviews of care plans must be monitored by the manager to ensure that they are thorough and accurate in their findings. Where people living in the home are empowered to make decisions about their lives the manager should ensure that evidence of this is available. Potential risks to people are minimised through the assessments completed the manager. EVIDENCE: The files examined for 2 of the people living in the home both contained detailed care plans to enable staff to meet their day-to-day needs consistently. Staff had completed a background and history document for each person that gave an insight into each person’s lifestyle and significant events before they moved into the home. The Limes DS0000069313.V348421.R01.S.doc Version 5.2 Page 12 Both people’s initial aims of the placement had been recorded and the care plans examined provided evidence of how those aims were being achieved. People’s long-term goals have not been identified; this is due in part to the short period of time people have lived at the home. The manager must now start supporting people to identify their long-term goals and develop plans as to how people will be supported to achieve them. Each person has a key worker. A range of support plans are in place to address peoples identified needs, and examples seen included: • • • • • • • • Therapeutic activities Communication needs Maintaining a healthy diet Personal care needs Support required to manage health needs Continence management Activities Required medication Not all of the plans seen had been reviewed regularly, in one case the reviews for May and August were missing. It is the homes aim that plans are reviewed monthly. The staff reviewing them had not signed a number of the completed reviews, the manager must ensure that this is addressed. In addition to this the staff complete monitoring forms for the support plans and risk assessments. A number were seen but they were not dated so it was impossible to identify when they were completed. The manager must ensure that this is addressed. Staff complete monthly reports that look at the environment, behaviour, communication, personal hygiene, physical health, sleeping, daily living skills, continence, diet, activities, family contact and current medication. When these reports are completed thoroughly they provide a good summary of what each person has done in a month and highlights any issues that need to be addressed. The manager must be mindful of the level of the recording to ensure that it is accurate and provide sufficient detail. This becomes a recommendation of this report. People living in the home have varying degrees of communication difficulties. To enable one person to understand their care more easily a care plan making use of signs and symbols was being developed. This was incomplete and the manager must ensure that it is completed. It is recommended that the manager should also assess the needs of the other people in the home to see whether they may also benefit from their plans being produced in this format. The Limes DS0000069313.V348421.R01.S.doc Version 5.2 Page 13 The manager must be mindful of empowering people living in the home to make decisions about their lifestyles and instances where staff support them to do this. Where possible the manager should ensure that evidence of people making decisions about their lives is evidenced. This becomes a recommendation of this inspection report. A range of risk assessments had been completed for both people. The Limes DS0000069313.V348421.R01.S.doc Version 5.2 Page 14 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 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home have limited social inclusion due to staffing. EVIDENCE: Speaking with staff and the manager activities for people living in the home have been limited. The manager stated that there are some weekends when people living in the home are unable to go anywhere, as there is no driver. The home has its own minibus but unfortunately only one staff member is able to drive it. Speaking to the manager they stated that they have been trying to address this through recruitment and explained that two more drivers will be starting at the home in the near future. Staff have a lot of ideas about activities that could be completed if more drivers were available. Staff commented that activities in the home could be a The Limes DS0000069313.V348421.R01.S.doc Version 5.2 Page 15 little limited. Surveys and comments from staff included “there needs to be more structured activities”. At present one person enjoys baking cakes with the staff, another person rides their bicycle around the garden, another enjoys watching DVDs. Some art sessions have been completed with staff in the home. In addition to this people attend various day services and a social club on a Monday evening. Good relationships are maintained with the families of people living in the home. Speaking to one parent they felt that the home communicated well with them. Of the completed surveys received by the CSCI comments were positive about the home in this aspect. In the AQAA completed by the manager they state that an improvement in the next 12 months must be greater social inclusion. The inspector supports this as at present this is does not appear to be happening. A requirement of this inspection report is for the home to ensure that people are supported to become part of the local community and that their social/leisure activity needs are identified and met. People must be empowered by staff to have choice about the activities they would like to be involved in and staff should be available to support them in achieving their goals. The home uses a 10-week rolling rota for the menu. The manager explained that this is used as a “base” and that people have a choice about what they eat. Records available in people’s files showed exactly what they ate. Snacks and drinks are available during the day. People are asked to be involved in preparing meals and whilst completing the site visit one person was observed helping prepare for the evening meal. The Limes DS0000069313.V348421.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 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s personal care needs are assessed and plans are in place that enable staff to meet those needs consistently. People’s health needs are assessed and other professionals are involved in meeting people’s needs appropriately. Medication administration must be improved to ensure that people living in the home are not put at unnecessary risks. EVIDENCE: People’s personal care support needs have been assessed by the staff and plans are in place to address those needs consistently. Both of the files examined contained completed health action plans. There was also evidence of people attending appointments with doctors and other professionals. Staff complete notes after each appointment detailing what was said. The Limes DS0000069313.V348421.R01.S.doc Version 5.2 Page 17 Records in the files examined showed that other professionals are involved in meeting the needs of people. A survey completed by one of these professionals was positive about the service provided at the home. Medication administration was examined. The current and previous medication sheets had been signed by staff confirming when medication had been administered. A shortfall identified was where staff had made changes to medication sheets on the instruction of a Doctor and not signed the change. This was brought to the attention of the manager and becomes a requirement of this inspection report. In addition to this shortfall while the home’s main fridge was being inspected a tube of cream was found, loose in the fridge. Medication must not be stored in the home’s fridge unless it is in a lockable container. In addition to this the cream had not been labelled with the date it was opened. This was brought to the attention of the manager. Other information stored in the medication file included examples of staff signatures, homely remedy consent forms and contra-indication information. All staff have completed the Look Forward medication assessment and training provided by the pharmacist. The Limes DS0000069313.V348421.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 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The complaints procedure being produced in different formats help to enable people living in the home to use the procedure. Potential risks to safeguarding adults will be further minimised by the staff team completing training. EVIDENCE: The home has a complaints procedure. This has been produced in 3 formats; large text, picture and formal versions. In addition to this the manager explained that they have created a concerns procedure, this is to address issues before they become a complaint. The manager provided evidence of using this procedure since the home opened in April. A member of staff gave a good explanation of other indicators to be aware of that show that someone is unhappy. Speaking to the manager they stated that the staff team had been booked to complete safeguarding adults training but had been unable to attend due to the recent flooding in Gloucestershire. This has not been re-booked as yet and it becomes a requirement of this inspection report that this is addressed. Financial records were examined. Staff recorded income and expenditure and receipts for spending were available. A recommendation of this inspection report is that two staff should sign for each transaction. The Limes DS0000069313.V348421.R01.S.doc Version 5.2 Page 19 Speaking to the manager they stated that sometimes there was insufficient funds left in the home’s petty cash to allow activities to take place. This was discussed at length with the manager and the inspector has recently spoken to a member of the organisation’s management team about this. They have reassured the inspector that funds will be made available each week that enable people to take part in activities when they wish. Whilst completing the site visit the inspector noted the use of a “baby monitor” in the lounge. It was not turned on at the time, but the inspector expressed his concern about the use of it. Use of this monitor could infringe on a person’s privacy and dignity. When speaking to the registered manager’s line manager about this they stated that they do not like the use of these monitors and it will be replaced a more appropriate system that will not infringe on the person’s privacy and dignity. This becomes a requirement of this inspection report. The Limes DS0000069313.V348421.R01.S.doc Version 5.2 Page 20 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, 25, 26, 27, 28, 30 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides people with a comfortable homely environment that is being personalised to meet their current needs. Maintenance is an issue around the home with a number of outstanding issues that have not been addressed in a timely manner. EVIDENCE: The home has been open since April this year. A tour of the premises was completed with the manager. All of the rooms in the home were seen. On the ground floor of the property there are 2 good size lounges, 1 provides digital television and a DVD player with 2 sofas. The other has a sofa and a small ball pool. In addition to these rooms there is a dining The Limes DS0000069313.V348421.R01.S.doc Version 5.2 Page 21 room with 2 dining tables. To the rear of the property is the kitchen which provides access to the garden. All of the radiators in the home are boxed in. The manager stated that they had requested that a hand washbasin was fitted in the kitchen, but this had not been completed as yet. Some shortfalls were noted with the communal rooms. The lounge with the ball pool did not have any curtains, and the dining room looked a little “jumbled” with a pair of curtains folded on a shelf and a staff file. It is a requirement of this inspection report that the manager ensures curtains are fitted in the front room to maintain peoples privacy and dignity. It is a recommendation of this inspection report that the dining room is tidied to make it look more homely and less jumbled. People’s bedrooms were seen with their permission. The staff are in the process of supporting people to personalise their bedrooms. This involves people being given the opportunity to decorate them to their taste and personalise them with their possessions. On the first floor there is a bathroom and a shower room. The floor covering in the shower room must be replaced, the main bathroom needs a new blind and the door handle was missing, although the lock worked. The manager supporting the inspector stated that it was sometimes difficult to get maintenance work completed. The manager stated that a maintenance person had been out to repair the door handle the day before this site visit. It is a requirement of this inspection report that maintenance issues are addressed in a timely manner and that the home develops an ongoing maintenance programme. The manager explained that they were employing a dedicated maintenance man. At the time of this site visit the home was clean and hygienic and there were no offensive odours. The Limes DS0000069313.V348421.R01.S.doc Version 5.2 Page 22 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 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home maybe being put at unnecessary risks due to insufficient information being gathered as part of the home’s recruitment process. Staff training records appeared incomplete making it impossible to confirm that staff have the necessary skills to meet peoples needs. EVIDENCE: The staff team at the time of this site visit consisted of 8 people. 2 staff have completed their NVQ (National Vocational Qualification) at level 2 or above in care. 2 other staff are currently completing NVQ’s at level 2 or above. Speaking with a member of staff they confirmed that they completed an induction when they started at the home and have also completed training in medication administration, fire safety and first aid training. The senior manager has completed Makaton communication training with the staff team. The manager must ensure that staff training records are kept up-to-date and this becomes a recommendation of this inspection report. The Limes DS0000069313.V348421.R01.S.doc Version 5.2 Page 23 As highlighted earlier in this report there have been some issues around staffing in the home. A discussion took place about how the manager ensures that people living in the home are not put at risk and that funding authority staffing expectations are met. Examining the rota it was clear that there have been times when less than 3 staff have been on duty and a number of occasions where the manager has covered shifts to ensure people are not put at risk. The manager has taken steps to address this and staff commented, “Staffing has improved recently”. This will be further improved with 3 full-time staff members being employed. The manager must continue to monitor this. Three staff files were examined in detail to ensure that they provided the documents required by these regulations. None of the files seen contained all of the information required. This was brought to the attention of the manager who stated that he had recognised this as an issue. It is a requirement of this inspection report that this is addressed. All of the staff files should now be reviewed to ensure that they meet the criteria of the regulations. The Limes DS0000069313.V348421.R01.S.doc Version 5.2 Page 24 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, 42 People who use the service experience Good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Although the home’s registered manager has resigned the CSCI has received assurances from the organisation to address the shortfalls of this report, and ensure a suitable candidate is put forward for registration with the CSCI. Health and safety checks completed by the staff team ensure that people are not put at unnecessary risks. EVIDENCE: At the time of this site visit the home’s manager was present. Since the site visit has been completed the registered manager has resigned from the position. The Limes DS0000069313.V348421.R01.S.doc Version 5.2 Page 25 The organisation’s managing director has maintained good communication with the CSCI throughout this period and has given their commitment to address the shortfalls identified in this report. The organisation have held interviews for the position of the registered manager of the home and will be proposing a new manager to the CSCI in the near future. The managing director has completed an audit of the service, and the inspector has discussed the findings of this site visit with them. Health and safety around the home is monitored regularly:• First aid boxes are checked weekly • A food probe is used with each cooked meal and records kept • Hot water outlets are checked daily • Fire alarms are checked weekly • The gas safety certificate was present • The hardwire electrical certificate was present • Portable appliance testing had been completed Cleaning chemicals are stored securely. The Limes DS0000069313.V348421.R01.S.doc Version 5.2 Page 26 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 2 3 X 4 X 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 2 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 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 X X X 3 X The Limes DS0000069313.V348421.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14(1) Requirement Whenever someone is admitted to the home the manager must ensure that as part of the assessment process the person’s community care assessment is obtained. All people living in the home must have a residency agreement/contract that meets the criteria of the regulations. Long-term goals should be identified for each of the people living in the home. Evidence of those goals being worked towards should then be available for inspection. People must be supported to take part in age, peer and culturally appropriate activities. People must be supported to become part of the local community. The manager must ensure that people’s rights are respected and responsibilities in their daily lives. When a doctor directs staff to alter information on a medication sheet staff should sign confirming who made the DS0000069313.V348421.R01.S.doc Timescale for action 02/11/07 2. YA5 5(3) 16/11/07 3. YA6 15 30/11/07 4. 5. 6. YA12 YA13 YA16 16(2) m 16(2) m 16(2) f, h, m 13(2) 02/11/07 02/11/07 02/11/07 7. YA20 19/10/07 The Limes Version 5.2 Page 28 alteration. 8. YA20 13(2) Creams and ointments that need to be stored at a refrigerated temperature must not be stored “loose” in the home’s main fridge. When creams, ointments and medicines are opened they must be labelled with the date. All staff must receive training in safeguarding adults. The home must ensure that the dignity and privacy of all of the people living in the home is respected at all times. Curtains must be fitted at the front window to ensure that people’s privacy and dignity is respected at all times. The home must develop an ongoing maintenance programme which clearly identifies when different aspects of the maintenance will be addressed. Maintenance issues must be addressed in a timely manner. The floor covering in the shower room on the first floor must be replaced. The blind in the main bathroom must be replaced. The door handle must be replaced on the door to the main bathroom. All of the staff recruitment records must reviewed to ensure that they meet the criteria of the regulations. 19/10/07 9. 10. 11. YA20 YA23 YA23 13(2) 13(6) 12(4) a 19/10/07 01/01/08 19/10/07 12. YA24 12(4) a 19/10/07 13. YA24 23(2) b, c, d 16/11/07 14. 15. 16 17. YA27 YA27 YA27 YA34 23(2) b 23(2) b 23(2) b 7, 9, 19 Schedule 2 02/11/07 02/11/07 02/11/07 02/11/07 The Limes DS0000069313.V348421.R01.S.doc Version 5.2 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard YA6 YA6 YA6 YA7 YA24 Good Practice Recommendations The manager should ensure that reviews are completed as prescribed by the home’s procedures. Monthly reports should be monitored by the manager to ensure that the correct level of detail is recorded in them. The picture/symbol format for a care plan should be completed. People living in the home should be empowered to make choices about their lives and staff should ensure records are available to support this. The home’s dining room should be tidied up as it looks a little jumbled. The Limes DS0000069313.V348421.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Limes DS0000069313.V348421.R01.S.doc Version 5.2 Page 31 - 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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