Inspection on 04/04/07 for The Limes

This inspection was carried out on 4th April 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 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 Limes 21/12/05

The Limes 26/07/05

The Limes 02/11/04

The Limes 30/06/04

The Limes 09/03/04

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Sunny Bank (P.R.S.) Ltd

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Alfred House Residential Care Home

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

CARE HOME ADULTS 18-65 The Limes 17 Walverden Road Brierfield Nelson Lancashire BB9 0PJ Lead Inspector Mrs Pat White Key Unannounced Inspection 4th April 2007 10:30 The Limes DS0000009515.V335239.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 DS0000009515.V335239.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 DS0000009515.V335239.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Limes Address 17 Walverden Road Brierfield Nelson Lancashire BB9 0PJ 01282 697414 01282 602121 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) Making Space Mrs Mary Caroline Spencer Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7) of places The Limes DS0000009515.V335239.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st December 2005 Brief Description of the Service: The Limes is a care home registered with the Commission for Social Care Inspection to provide accommodation and personal care for 7 adults with a mental disorder (excluding learning disability and dementia). The building dates back to the 16th Century and adjoins a Quaker meeting house. It is situated close to local amenities such as shops and pubs and is approximately half a mile from Brierfield, and one mile from Nelson town centre. Accommodation is provided on two floors in seven single bedrooms, all of which have en suite facilities. There is a lounge on each floor, with the lounge on the ground floor providing space for dining. All furnishings and fittings are domestic in character. The home has designated smoking areas. The home has a Statement of Purpose and a Service User Guide providing information about the care provided, the qualifications and experience of the owner and the staff, and the services the residents can expect if they choose to live at the home. The weekly fees charged by Making Space were £462, and service users paid for clothes, entertainment and holidays etc out of their own money. The Limes DS0000009515.V335239.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at The Limes on the 4th April 2007. The purpose of this inspection was to determine an overall assessment on the quality of the services provided by the home. This included checking important areas of life in the home that should be checked against the National Minimum Standards for Adults (aged 18 – 65), and checking the progress made on a few matters that needed improving from the previous inspection. The inspection included: touring the house, observation of life in the home, looking at service users’ care records and other documents, written information supplied by the home prior to the inspection (the pre inspection questionnaire) and discussions with the acting manager and another member of staff on duty. All the service users were spoken with at the time of the site visit, though not all gave their views about the home. However all the service users completed and returned, survey questionnaires from the Commission. Three relatives also returned completed survey questionnaires. These views and those of the staff spoken with are included in the report. What the service does well: The written information about the service users and their individual needs was detailed, and kept up to date to reflect changes in circumstances. This provided staff with useful information from which to provide support. The service users took part in a range of activities both inside and outside the home. This kept service users usefully occupied and gave them the opportunity to meet other people. One service user said, “I feel happy at the Limes”. The service users and staff had good relationships and there was a friendly atmosphere in the home. Visitors were made welcome at all times. The service users were well supported to maintain positive relationships with their families and the relatives who completed the questionnaire were satisfied with the care given. One relative said, “we think they do a real good job with people at the Limes and take good care of them” The meals served were of a high standard and suited the tastes and preferences of the service users. The service users who were asked said that the food was good. One said the “food is really good here”. The service users had access to all the health care they needed and medication was managed safely in the home. This helped to keep the service users as well as possible. The Limes DS0000009515.V335239.R01.S.doc Version 5.2 Page 6 There were thorough systems and policies and procedures in place to ensure service users were listened to and protected from harm. The home was maintained, furnished and decorated to a high standard, and was a pleasant, clean safe place for service users. The outside areas were also well kept, and pleasant, and provided attractive areas for the service users to enjoy in nice weather. All the staff were well qualified, and had a wide range of training opportunities, which gave them a good understanding of their role, and the needs of the service users. They were also eager to improve the service in any way they could What has improved since the last inspection? What they could do better: More details of the personal support and supervision service users needed should be written down in the care plan so that staff are clear what and how support should be provided. The system for making decisions on behalf of service users about freedom and choices could be clearer, and should demonstrate who makes the decisions and why. Decisions that could be seen as restricting service users’ freedom should be made in conjunction with the other professionals (such as social workers and Community Psychiatric Nurses) involved in service users’ care, so that these decisions are made in the service users’ best interests. Also any standard practices and “rules” of the house which restrict service users’ freedom should be stated clearly in the written information given to people. The system for reviewing and determining staffing levels in the home could be improved so that there are enough staff on duty at all times to enable service users to have sufficient choice in terms of independence and activities. The records kept about complaints and the action taken should be detailed enough to include all the investigations, so there is a clear record of what action has been taken and how the outcome has been achieved. There should be sufficient information about staff recruitment kept in the home, and in accordance with the Care Homes Regulations, to determine whether or not the procedures were sufficiently thorough to protect service users. The Limes DS0000009515.V335239.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Limes DS0000009515.V335239.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 DS0000009515.V335239.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): 1, 2 & 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission procedures enabled the registered person and the prospective service users to determine whether or not the home is able to meet the service user’s needs. EVIDENCE: Written information was available for residents in the form of a service users guide and statement of purpose. Both documents were presented in a suitable format and met with legal requirements. The service users guide had been distributed to all residents since the previous inspection. Care records indicated that all those residents who had lived at the home for some time had an assessment of their needs, which was periodically reviewed by the staff in the home. The assessment of the most recently admitted service user had been completed following the previous inspection and a legal requirement. The inspection methods, including conversations with the acting manager and the most recently admitted service user, showed that this service user had visited the home prior to admission and was given the opportunity to view the vacant room and meet the other service users. He said that he had settled well and liked living at the Limes. The Limes DS0000009515.V335239.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, 8 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans addressed in detail the changing needs of the service users. Service users had some choices in their everyday lives and were able to participate to a satisfactory level in the running of the home. However there was a lack of clarity about how decisions were made about some matters that could be seen as a lack of service users’ choice and freedom. EVIDENCE: From the service users’ records seen, it was evident that all the service users had a plan of care, based on the assessment of their needs. The plans set out in detail the action needed to be taken by staff to ensure all needs were met. There was evidence that the plans had been reviewed at least every six months and agreed with the service user. The plans had been updated in respect to any changing needs as frequently as necessary. Whilst there was a good level of detail in most areas of the care plan, more written information about the personal support and assistance required would be beneficial (see standard 18). The Limes DS0000009515.V335239.R01.S.doc Version 5.2 Page 11 In discussion with the acting manager it was not clear how some decisions were made about whether or not some service users’ choices about lifestyle and routines could be accommodated. It was not clear who was involved in what decisions, whether or not other professionals were involved (the multi disciplinary team) and whether or not some decisions about individual service user’s wishes regarding freedom of choice were made in the interest of the service user or in the interest of the staff group, for example staying out of the home late at night Some of these matters were not explained in the written information supplied to service users, for example service users not having a front door key, and the time in the evening that service users were routinely expected to be back in the home (see below). However the service user questionnaires showed a satisfactory level of satisfaction about choice and freedom in the home. Four out of 7 said they can “always” chose what to do each day, 3 said “usually”. Six service users said they could do what they wanted in the day, the evening and at the weekend. One service user did not answer this question. None of the service users managed their own finances – the manager was the official appointee for all of them. The acting manager said that none wanted the responsibility, and also wished their personal allowance spending money to be kept in the office safe. Records and checks of the monies kept in the safe showed that the monies were managed safely, with appropriate records being kept and service users signing for money deposited and received. During conversations with service users and staff it was evident that service users were consulted both informally and formally about life in the home. Service users’ meetings were held at regular intervals and provided an opportunity for them to air their views. The minutes showed that a variety of topics were discussed and that some service users participated. The acting manager stated that service users could be involved in some aspects of running the home, such as staff recruitment and interviews and staff meetings, but in general chose not to be. There was information about advocacy in the home should service users need this service. Service users were encouraged to be independent and would go out un accompanied if possible. Some service users were seen coming in and out of the home as they wished at the time of the site visit. There were risk assessments to support this, and for some other aspects of promoting independence. However service users did not have keys to the front door and there were no risk assessments to underpin this decision (see standard 16) The Limes DS0000009515.V335239.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, 14, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were encouraged to lead a lifestyle of their own choosing within a structured framework of organised occupational and leisure activities, and which included maintaining strong links with their families. The meals served were healthy and appetising and were in accordance with the service users’ preferences. EVIDENCE: The care records and discussions with staff and service users demonstrated that service users had opportunities to maintain and develop practical life skills and take part in fulfilling activities. Service users were encouraged and supported to participate in the life of the home and carried out domestic tasks, such as helping in the kitchen and tidying bedrooms, in accordance with their abilities and interests. Service users took part in activities in the local community, which included walking, going to the cinema, shopping and restaurants. Staff provided The Limes DS0000009515.V335239.R01.S.doc Version 5.2 Page 13 assistance with activities as necessary, and had knowledge of events in the nearby area. Several service users also attended a local college, some went to a “drop in” for people with mental health problems and one person went to church on a regular basis. Since the last inspection service users had been on a holiday near the Lake District. One service user chose not to join in any of the communal activities. The service users were supported to maintain relationships with their friends and families. During the inspection one service user visited her mother; one of two weekly meetings. Relatives were invited to the festivities on Christmas day. Of the three relatives who completed a questionnaire from the Commission, one said the home “always” helped the service user to keep in touch, one said “usually”, one said “sometimes”. Two said the home “always” kept them up to date with important matters, one said “usually”. With respect to the home’s routines, service users indicated on the questionnaires that routines were flexible enough to suit individuals, with these routines being more flexible at the weekend when service users did not have a structured programme. Service users had keys to their rooms to enhance the their rights to privacy. Some service user rights, such as regarding opening mail, telephone facilities, smoking and alcohol, were explained in the written information about the home. However some other restrictions on service users, which were potentially controversial, were not made explicit, such as service users having to be in at a certain time at night, including the weekend, and not having a key to the front door (see standard 8). The records of food served showed a good variety of traditional and more modern dishes and which appeared to suit the preferences of the service users. At the time of the site visit the meals served were appetising, of sufficient portions and nutritious. One of the service users spoken with said the food was “very good” and service users appeared to enjoy the meal at the time of the site visit. There was a cook employed in the home who knew the service users likes and dislikes, and these were recorded in the care plans. Meals were usually discussed at the residents’ meetings and they are asked about this in the quality monitoring questionnaires. People with specific dietary requirements were catered for, such as those with diabetes and those wanting to lose weight. The Limes DS0000009515.V335239.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 excellent. This judgement has been made using available evidence including a visit to this service. Personal support was provided in a manner, which was appropriate for individuals and respected the service users’ rights to privacy and dignity. The service users’ healthcare needs were identified and met, and service users’ medication was managed safely in the home in accordance with their wishes. EVIDENCE: The service users’ individual care plans set out the personal support required, and provided some details of how this support was to be delivered. However for at least one service user more details regarding how this support should be provided and the assistance required in relation to the what he could do, would be beneficial. All had en suite rooms with a bath or shower. This enhanced the privacy and dignity arrangements for the service users and there were no restrictions on the use of these personal facilities. Consistency and continuity for service users’ support was assisted by the key worker system. Healthcare needs were appropriately assessed and were included in the care plan. There was evidence to indicate the residents had access to NHS services, The Limes DS0000009515.V335239.R01.S.doc Version 5.2 Page 15 including dentists and chiropody, and the advice of specialist services had been sought as necessary. All service users had involvement with the psychiatric services and appropriate health screening. Practices followed by staff with respect to the management and administration of medication ensured that service users were given medication correctly. Policies and procedures were developed in accordance with the Royal Pharmaceutical Guidelines. Systems were set up with the community pharmacist so that staff in the home checked the prescriptions prior to dispensing to check for errors and to ensure that there was no secondary dispensing of medication when service users went on leave from the home. None of the service users were responsible for their own medication and there was evidence of service users’ consent on the care plan to staff taking this responsibility. Other areas of good practices included, all homely remedies being checked with the GP and written on the Medication Administration Records (MARs), written details of when PRN (“when required”) medication should be given, and medication stored securely and the temperature monitored. Also all staff had undertaken or were undertaking, appropriate training for the management of medication. However two people (a witness) did not always sign the hand written additions or alterations to the MARs. The Limes DS0000009515.V335239.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. Systems were in place to ensure any concerns of residents would be acted upon. Appropriate policies and procedures and staff training were in place to help protect service users from abuse. EVIDENCE: Both informal and formal arrangements were in place for the registered manager and staff to listen to and act on the views and concerns of residents, by means of the resident’s meetings and everyday conversation. There was a formal complaints procedure that complied with the Regulations and to which service users had access. In the questionnaires competed by the service users six said that they knew who to speak to if they were not happy with something and knew how to make a complaint. One said he didn’t. Two relatives said that they knew how to make a complaint and all 3 said the home always responded appropriately to their concerns. The PIQ stated that there were two complaints made to the home since the previous inspection. However all the investigations for one complaint had not been fully recorded so it was unclear how the conclusion of the investigation had been achieved. There had been no suspicions or allegations of abuse in recent times. There were satisfactory procedures that were in accordance with the Government guidance “No secrets”, and that would help protect service users. The acting manager knew what to do in the event of an incident being reported to her. The Limes DS0000009515.V335239.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service users were provided with a high quality, clean, safe and well maintained home. Personal accommodation was of a high standard which allowed service users comfort, privacy and independence. EVIDENCE: The Limes is a listed building attached to a Quaker Meeting House. The Bradford and Northern Housing Association owned the property and were responsible for the up keep of the structure of the building. Making Space was responsible for the decorating and furnishing of the home and for which there was an annual budget. The building is set in its own grounds with car parking facilities for visitors. At the time of the site visit the grounds were attractive and well maintained and provided a pleasant area for the benefit of service users. The Limes DS0000009515.V335239.R01.S.doc Version 5.2 Page 18 Accommodation was provided in 7 single rooms, all of which had an en suite facility with shower. The bedrooms were spacious, and decorated and furnished according to personal tastes and preferences, with music systems and/or TVs according to service users’ wishes. Each bedroom had drink making facilities, and seating arrangements for visitors. The en suite facility in the bedrooms enhanced the privacy of each service user and promoted independence. In addition to the en suite facilities there were also two communal bathrooms with domestic baths, to offer service users a choice. Communal space consisted of one lounge/dining room on the ground floor and a further lounge on the first floor that was a designated smoking lounge. The front porch, which had seats, was also a smoking area. Smoking was not allowed in other areas of the home. All the furnishings and fittings throughout were domestic in character and of a good quality. At the time of the site visit, all areas of the premises were well maintained, well furnished and comfortable. The home had a planned maintenance and renewal programme. Records were kept of the work carried out. The home was also clean and free from offensive odours at the time of the site visit, and service users confirmed in the questionnaires that a high standard of cleanliness was maintained. There was a laundry room, which was well kept, and procedures that allowed service users to assist with their own personal laundry. The Limes DS0000009515.V335239.R01.S.doc Version 5.2 Page 19 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, 33, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was an experienced, skilled and well - qualified staff team that ensured the needs of the service users were understood. The recruitment procedures helped to protect service users from unsuitable staff. However it was not certain if one member of staff on duty was sufficient to meet the service users’ needs at all times. EVIDENCE: The inspection methods, including the PIQ, indicated that the staff team was well qualified and experienced, with all the six support staff qualified to at least NVQ level 2, and most to level 3 and 4. The rotas, and discussion with the acting manager, showed that during the day, Monday to Friday, there were two members of support staff on duty, but that from 4.00pm till 9.00am, and all of the weekend, there was only 1 member of staff on duty. There was evidence that staffing levels were reviewed and adjusted temporarily according to need, for example if it was assessed that 1 member of staff would be at risk working alone at certain times. However at the time of the site visit there was also evidence that The Limes DS0000009515.V335239.R01.S.doc Version 5.2 Page 20 another member of staff would be beneficial at certain times, to increase the choice for service users of activities that required staff support. The Making Space business plan acknowledged this view, and stated the situation would be reviewed. A cook and cleaner were also employed in the home to ensure high standards in relation to cleanliness and food were maintained. There had been no new members of staff recruited since the previous inspection, at which time the home’s recruitment procedures were more fully assessed. However at this site visit there was no evidence in the home to show that the most recently appointed person had not commenced work until the Protection of Vulnerable Adults check had been obtained. The acting manager subsequently confirmed that this member of staff had not commenced work until the POVA check was received. The PIQ and discussions with staff indicated there was a variety of training opportunities, some of which were run by Making Space and some of which were directly relevant to the field of mental health. All staff had training portfolios and structured supervision with a manager that identified training needs and opportunities. The member of staff spoken with confirmed the training opportunities available and that she had undertaken appropriate Induction training during the first weeks and months of employment. The Limes DS0000009515.V335239.R01.S.doc Version 5.2 Page 21 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. Service users benefited from a well run and managed home and which took into account the views of service users and their relatives. Appropriate policies and procedures were in place to safeguard the health and safety of the staff and service users. EVIDENCE: The registered manager had left employment with Making Space just prior to the site visit. One of the deputy managers was the acting manager. A new manager had been appointed and was awaiting all the necessary recruitment procedures to be completed. The Making Space organisation, its corporate policies and procedures and in particular the area manager ensured the manager of the home was well supported. The Limes DS0000009515.V335239.R01.S.doc Version 5.2 Page 22 Staff spoken with felt well supported by each other and the organisation. Talking to staff and looking at records confirmed that staff had regular one to one structured supervision. The home had good quality monitoring systems. Service users and their relatives were sent questionnaires every 6 months. Other professionals involved in the service users’ care were also sent questionnaires. The results were collated and analysed and included in the home’s Business Plan. Service users’ meetings also informed the Business Plan. There were a wide range of health and safety policies and procedures to help ensure a safe environment for service users and staff. Staff received health and safety training, which included moving and handling, food hygiene, first aid and fire safety. The PIQ and records seen during the site visit confirmed that gas and electrical systems were serviced at appropriate times and that the water supply had been tested and found to be free from the Legionella bacteria. To minimise the risk of scalding all water outlets were fitted with preset valves and window restrictors were fitted as appropriate. The fire records viewed showed that the fire precautions in the home were satisfactory. The equipment was maintained appropriately, there were monthly fire drills and weekly testing of the fire alarm. There were detailed fire risk assessments under each room and service users also attended fire safety training. The fire alarm panel had been upgraded in line with the requirements of the Fire Authority and a previous requirement had therefore been met. The Limes DS0000009515.V335239.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 x 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 4 25 4 26 4 27 4 28 3 29 X 30 3 STAFFING Standard No Score 31 x 32 4 33 2 34 2 35 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 2 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 X 4 X X 3 x The Limes DS0000009515.V335239.R01.S.doc Version 5.2 Page 24 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 YA7 Good Practice Recommendations Details of all the personal support and supervision service users required, and how this should be provided, should be written in the care plan. There should be a clear process for making decisions about service users choices and personal freedom that involves the service user, the staff and other professionals if need be. Any rules, such as about front door keys and the time service users have to be in at night, should be made explicit in the written material given to service users, for example the Service user Guide. It is recommended that any hand written alterations and or additions to the medication administration records are signed by two members of staff (witnessed) to help ensure that this information is accurate. All the investigations made in a complaint investigation must be thoroughly recorded, including conversations with people so that there is a clear record of what investigations have been conducted and therefore how the outcome has been achieved. DS0000009515.V335239.R01.S.doc Version 5.2 Page 25 3 YA8 4. YA20 5. YA22 The Limes 6. YA34 There should be sufficient information about staff recruitment kept in the home, and in accordance with the Care Homes Regulations, to evidence whether or not the procedures were sufficiently thorough to protect service users, such as dates of POVA/CRB applications, dates of receipt, disclosure numbers and details of references. The Limes DS0000009515.V335239.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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. 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