Inspection on 07/11/05 for The Limes

This inspection was carried out on 7th November 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Limes 24/04/09

The Limes 26/04/07

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 The Limes 13 Welholme Road Grimsby North East Lincs DN32 0DR Lead Inspector Christina Bettison Announced Inspection 7th November 2005 09:30 The Limes DS0000064078.V263086.R01.S.doc Version 5.0 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 DS0000064078.V263086.R01.S.doc Version 5.0 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 DS0000064078.V263086.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Limes Address 13 Welholme Road Grimsby North East Lincs DN32 0DR 01754 890540 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) Linkage Community Trust Care Home 8 Category(ies) of Learning disability (8) registration, with number of places The Limes DS0000064078.V263086.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the Manager is registered with the CSCI within 3 months of registration. This is the first inspection following registration. Date of last inspection Brief Description of the Service: The Limes is a semi-detached property situated in a pleasant residential area of Grimsby overlooking an established park. It benefits from it’s own discreet established garden and has the benefit of car parking facilities. On the ground floor there are kitchen, dining room, TV lounge/conservatory, a lounge, an office, laundry, WC, a bathroom and entrance/reception area. There are three bedrooms on the ground floor and a staff sleeping in room, all of which are en suite. On the first floor are 3 bedrooms all of which are en suite. On the second floor there is a separate 2 bed roomed flat that consists of two bedrooms, a lounge and a kitchen/diner and a bathroom. The Limes DS0000064078.V263086.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Limes is a newly registered care home, which is part of the Linkage Community Trust residential services. The home opened on 25/7/05 with the service users moving in over 25th, 26th and 27th July 2005. Tina Bettison carried out the announced inspection of the Limes Care Home over 8 hours. Service users that were at home on the day of inspection were encouraged to play a very active role in the inspection. A tour of the premises took place and staff files and care records were examined. Rotas, medication records, staff lists and training records were examined. Staff, managers, service users and a visiting relative were spoken to. Care practices and interactions were observed during the inspection. Comment cards were received from other relatives that were unable to be at the home on the day of inspection. What the service does well: Linkage is a very good organisation that is well run and managed from the directors to the support workers. They have a lot of policies and procedures (rules) that are regularly reviewed and changed in order to promote service users rights and best interests and make sure that the staff know how to do their jobs properly. Service users are at the heart of the organisation and their views/wishes are taken into account by the use of questionnaires, house meetings, the pointers committee and by managers and staff that make sure they are involved. Linkage Community Trust provides an excellent service for young adults with a learning disability and other needs. Their primary aim is to enable the young people to develop as much independence as possible, whilst helping them to be more confident. They provide a wide range of educational training on life skills and on the use of buses and road safety. Service users have detailed care plans and are involved in the preparation of their care plan and therefore know that their specific needs and goals will be met. The Limes DS0000064078.V263086.R01.S.doc Version 5.0 Page 6 The house provides excellent accommodation for the young people; it has been refurbished to a very high standard, with good quality fittings and furnishings. All bedrooms are en suite and the service users have personalised their rooms. The house is located in the local community and is on a bus route making all leisure facilities and shops easy to get to, some service users go to work experience placements and pursue hobbies. Service users are given enough information about the Limes in order to make a choice about whether to live there or not, which is provided in ways that all service users can understand. Service users physical and emotional needs are met, by the provision of a wide range of healthcare professionals and outside agencies and a caring and professional team of staff promotes their privacy, dignity and respect. Contact with families is important at linkage and all service users families are encouraged to visit and stay for meals. The staff team is provided in enough numbers to meet the needs of service users and they were observed to be kind and caring and promote independence. Service users are protected from harm by a robust complaints procedure that is provided in an accessible format and all service users are aware of and a Protection of Vulnerable Adults policy and procedure that the staff and manager are aware of their responsibilities within this. Comments received from a visiting relative included “ the transition went really smoothly, linkage were very helpful, communication was open and honest. We are very pleased with the environment and our son is developing his independence. Linkage enabled our son to maintain a relationship with the staff that had worked with him previously this was very important in helping him to settle in his new home. The limes has a great staff team, they are very supportive and are helping us to let go. I have no doubts about our sons safety and security.” Comments received from relatives on comment cards included; “The staff are always friendly, approachable and helpful. I am very happy with the service.” “Our son has been in the Limes for 11 weeks and seems happy and settled. I can only give praise about the house and the carers, who in my opinion are excellent” “We are impressed by the dedication shown by the staff. We know that our son is happy and we have great confidence in Linkage” The Limes DS0000064078.V263086.R01.S.doc Version 5.0 Page 7 “The Limes is a real home we are impressed with the standard of care and the warmth and friendliness of the staff” Comment cards were received from all 8 service users and included the following comments; “I like the meals in the Limes, and I have nice times at the Limes” “I like to live in the Limes with staff and other residents” “I like the town and shops” 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 Limes DS0000064078.V263086.R01.S.doc Version 5.0 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 DS0000064078.V263086.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Service users are provided with sufficient information and opportunities to visit and test drive the home in order to choose whether it will meet their needs however the lack of assessment from the placing authorities compromises this. EVIDENCE: The Limes had a statement of purpose and service users guide, which met the requirements of schedule 1 and NMS 1.2. They gave clear information about their aims, philosophies and values and what service users and their families could expect. Both documents were made available in written text, with photographs of the house and rooms in the service user guide and makaton symbols and audio cassette if requested. Attached to the service user guide is a statement of terms and conditions detailing what they can expect from the home and their rights and responsibilities. The inspector was able to examine these documents and confirmed with service users and relatives that they understood their purpose and had been given copies. The Limes DS0000064078.V263086.R01.S.doc Version 5.0 Page 10 The Residential services manager was responsible for assessing service users needs prior to admission, documents were seen to evidence this and relatives confirmed that they had been involved in the process. However the inspector was informed that the home had not received copies of the Community care Assessments and care plans from the placing authorities. This means that the home may not be aware of the service users full range of needs and therefore may not be able to meet them. Relatives and service users spoken to confirmed that they had had an opportunity to look around the home and had also looked at other homes prior to making a decision to move into the Limes. Linkage employs a professional support team made up of qualified social workers, psychiatrist, clinical psychologist, speech and language therapist, visual impairment specialist and a registered nurse. The Limes DS0000064078.V263086.R01.S.doc Version 5.0 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10 Service users have detailed care plans and are involved in the preparation of their care plan and therefore know that their specific needs and goals will be met. EVIDENCE: Samples of Care plans were examined as part of the inspection process and had been developed to cover all aspects of the service users needs and included; medical needs, communication, vocational training, money management, personal care, behaviour management, household chores and road safety. They also included person centred planning goals. Each file contained a focus page which gave staff a quick overview of a service users needs, dietary requirements, information on advocacy services, a personal history, behaviour management plans and health action plans. All staff talked about the care plans being a living document and as such it was important to ensure the information was factually correct and updated regularly. The Limes DS0000064078.V263086.R01.S.doc Version 5.0 Page 12 Staff were able to confirm that the care plans were kept under constant review and that they were informally reviewed monthly and formally reviewed every 3 months. Service users spoken to confirmed that they are encouraged to participate in the development of their own care plan. Service users spoken to throughout the inspection confirmed that they knew what skills they were hoping to develop. Staff were able to explain that since the service users had moved into the house their needs and skills could quickly change therefore it was important to continually update care plans. Risk assessments were in place for any areas that posed a risk to service users and measures put in place to minimise the risks, i.e. personal safety, road safety and leisure activities. There was evidence of excellent daily recordings and all service users had had their initial review with the placing authority. All service users had a key worker and were able to tell the inspector who this was and explain what their specific role was. Service users were enabled to be as independent as possible this was confirmed by taking to staff, service users and relatives, who stated that the main aim was to “promote independence”. All service users managed their own personal allowance with support. The inspector observed service users being offered many opportunities to participate in the day to day running of their own home; they have house meetings once a week. Staff and service users confidential information was observed to be securely kept and handled in accordance with the Data Protection Act. Lockable facilities were used and service users are consulted about when and where there information can be shared. Staff were observed to knock on doors and to ask permissions to enter bedrooms. Linkage has a policy on sharing information with partner agencies and a policy/procedure for missing service users. The Limes DS0000064078.V263086.R01.S.doc Version 5.0 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17, Service users are enabled to develop as much independence as possible, whilst building on their confidence and self-esteem. They are provided with a wide range of training in life skills and are enabled to participate in the local community. Staff focus on the individual person and ensure that they are listened to and have a say in their daily lives by promoting an active service users committee and regular meetings in the house. EVIDENCE: Service users social, emotional, communication and independence skills are developed and maintained. Specialist intervention and support is provided by a professional support team made up of qualified social workers, psychiatrist, clinical psychologist, speech The Limes DS0000064078.V263086.R01.S.doc Version 5.0 Page 14 and language therapist, visual impairment specialist and a registered nurse, that are all employed by Linkage. This was evidenced by the care plans and by talking to staff and relatives. Household activities are shared amongst the service users in the house. Some service users have secured work experience placements and all participate in leisure activities in the community e.g. bowling, swimming, cinema, theatre, gym, disco’s, shopping and pursue their own hobbies such as visits to the pub, snooker and pool club, Grimsby college art class, Duke of Edinborough award. Planned trips were organised on a weekend. The inspector was informed that all service users took part in an Art exhibition at the Grimsby Library from 18-20th October 2005 to celebrate the achievements of people with a learning disability living in North East Lincs. The joint entry from the service users living at the Limes called “building independence” was awarded a prize of a set of oil paints. The service users were very proud of this. Transport is provided in the form of mini buses, people carriers and company cars, however the emphasis is on the use of public transport and independent travel. Contact with relatives is encouraged and maintained. Relatives are welcomed to visit and relatives spoken to said that staff kept them well informed of progress, problems and/or illness. Service users all stated that they are encouraged to make choices and can have a key to their room if they wish. Service users had unrestricted access to the houses and gardens. Service users take a turn in the cooking of meals and were keen to explain to the inspectors that they held weekly meetings to agree the menus. Meal times were observed to be flexible and unhurried and service users are encouraged to follow a healthy eating option but taking into account their ages, likes and dislikes. The Limes DS0000064078.V263086.R01.S.doc Version 5.0 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20, Service users physical and emotional needs are met, by the provision of a wide range of healthcare professionals and outside agencies and a caring and professional team of staff promotes their privacy, dignity and respect. EVIDENCE: Discussion with Service users, families and staff and observations confirmed that the staff promoted service users dignity, privacy and respect. Staff were observed to behave in an appropriate manner towards service users. Times for getting up and going to bed were flexible up to a point, service users explained that because they had to be up early during the week to go to work experience placements and educational classes they were encouraged to be in bed at a reasonable time during the week, however at a weekend they could stay up and watch films, visit friends, go the pub etc. Individual likes and dislikes were recorded on the care plan and service users told the inspector that they had a key worker. Records examined confirmed that service users had access to a wide range of health professionals e.g. psychiatrist and psychologist, speech and language therapist and visual impairment specialist. The Limes DS0000064078.V263086.R01.S.doc Version 5.0 Page 16 Service users are enabled to visit the GP, however the inspector was informed that because of the shortage of NHS dentist in the local area most of the service users have retained their dentist in their home town and that they visit the dentist when they go back to their parents for a visit. Emergency dental services are available if needed. Linkage has robust medication policies and procedures that include receipt, storage, administration and disposal of medication. Service users who wish to self medicate are encouraged to work toward this with a graduating selfmedication programme. The manager and staff will assess the service user prior to commencement and a risk assessment is undertaken. Facilities are made available for service users to lock their medication away in their room. At the time of the inspection there were two service users on the self medication programme and this was going well for both of them. The medication systems were examined by the inspector as part of the inspection process and found to be well managed and robust. All staff are given medication administration induction training which includes a competency check. The Limes DS0000064078.V263086.R01.S.doc Version 5.0 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Service users are protected from harm by a robust complaints procedure that is provided in an accessible format and all service users are aware of and a Protection of Vulnerable Adults policy and procedure that the staff and manager are aware of their responsibilities within this. EVIDENCE: The home had a well-developed complaints procedure. This contained contact details for the CSCI and the ombudsman and gave an assurance that service users and their families would not be victimised for making a complaint. The timescale given for responding to complaints was 21 days. The complaints procedure was also available in Makaton symbols and on audiocassette. In addition to the above the home also had a service user specific complaints policy. Each service user had been given a copy of the complaints policies in written and Makaton format, and Social Services “Right to Complain” leaflet. These were kept in service users individual files. All minor issues were dealt with through the house meetings. More serious issues were taken to the manager and a mechanism is in place for responding to these areas of concern and/or complaint. There had been three complaints from service users since registration, which had been dealt with appropriately. The Limes DS0000064078.V263086.R01.S.doc Version 5.0 Page 18 The manager checked the complaints log on a regular basis. The home had a copy of the “Multi agency Guidelines for the Protection of Vulnerable Adults” and an in house abuse policy and procedure that links in with the “Multi agency Guidelines for the Protection of Vulnerable Adults” in respect of alerting, referral and investigation. All service users had been given a copy of the leaflet from the local authority on abuse and this was kept on their individual file. The home has a separate whistle blowing procedure. There was evidence from the home’s recruitment and selection processes, staff training records, complaints log and the use of risk assessments that the manager ensured that service users were protected and safeguarded from abuse. Training records evidenced that staff had received training on the protection of vulnerable adults and the staff spoken to were clear about their responsibilities within the POVA procedures. The home had a policy for dealing with physical and verbal aggression by a service user. The Limes DS0000064078.V263086.R01.S.doc Version 5.0 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29,30 The Limes provides excellent accommodation it has been refurbished to a very high standard, with good quality fittings and furnishings. All bedrooms are en suite and the service users have personalised their rooms. The house is located in the local community and is on a bus route making all leisure facilities and shops easy to get to. EVIDENCE: The Limes is a traditional Victorian property that has been sensitively refurbished to a very high standard to provide small group living for 8 young adults. It is situated in a residential area of Grimsby overlooking Peoples Park. The home has been tastefully decorated and all necessary provision made to provide accommodation, personal care and ongoing support to the service user group. The house comprises of a lounge, a lounge/TV room, a dining room, laundry room and a kitchen. It has 6 en suite bedrooms with either a shower or bath, and a 2 bed roomed flat that comprises a large lounge, kitchen, shared bathroom and 2 bedrooms. The Limes DS0000064078.V263086.R01.S.doc Version 5.0 Page 20 All fixtures/fittings and furniture are of a very good quality and on the day of inspection the house was extremely clean and tidy. The service users were all very proud of their new home and were eager to show the inspector around. There is also a managers office, and staff sleeping in room. The house is very spacious enabling service users to spend time with each other or alone as they choose. Outside is a drive and pleasant gardens. The Limes DS0000064078.V263086.R01.S.doc Version 5.0 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36 Service users are supported by a competent and effective staff team in order to meet service users needs, however the lack of mandatory training provided compromises this. EVIDENCE: The Limes DS0000064078.V263086.R01.S.doc Version 5.0 Page 22 The staff team at the Limes are new however some of them have worked for Linkage at other homes and some are new to linkage. There are five staff on the team and a regular bank worker. There are always two staff on duty and usually the manager also. One of the staff on duty will always be the full time houseparent whose shift pattern is Friday 9.00 am – Monday 9.30am including the sleep ins then return Wednesday 9.00am – Friday 9.30 am. The other full time houseparent will work the opposite shift. They are supported by two part time house parents and the manager who works full time usually Monday to Friday. A training and development plan for the home was seen. Individual training and development plans had been completed for staff. Training records, interviews with staff and observation evidenced that staff had the skills and qualities required to meet service users needs, however only one of the care staff and the manager working in the home had achieved NVQ 2 or above. A requirement for 50 of staff to have achieved NVQ level 2 has been made. The training programme was a rolling programme providing all mandatory training and service specific training to enable staff to meet the needs of the service users. This included medication, incontinence, autism, non crisis intervention, HIV awareness, DDA, epilepsy, protection of Vulnerable Adults, equal opportunities and race equality, however from the examination of training records it was evident that not all staff were up to date with mandatory training and not all staff had completed service specific training in a timely fashion. This must be addressed. New staff were enrolled on the home’s induction and foundation programme, which met the Learning Disability Award framework standards. From examination of staff files and discussion with staff it was evident that all staff have clearly defined job descriptions and are clear about their role and how this fits in with the linkage aims and meeting service users needs. Observation of staff practices confirmed that they have developed appropriate relationships with the service users and treat them in an age appropriate way and with the utmost of dignity and respect whilst offering guidance and support in a sensitive manner. The staff team are supported by a wide range of health professionals e.g. psychiatrist and psychologist, speech and language therapist and visual impairment specialist. Linkage recruitment policies and procedures are robust and examination of staff files confirmed that all staff have had CRB disclosures, all identity as required by regulation was in place and references obtained. Staff are subject to a 6 month probationary period following appointment and a detailed The Limes DS0000064078.V263086.R01.S.doc Version 5.0 Page 23 induction programme is undertaken. Staff confirmed that they had been given a copy of the GSCC code of practice. The staff team are well supported, records examined and discussions with staff confirmed that the home has made a good start to ensuring that formal supervision is provided at least 6 times a year. The Limes DS0000064078.V263086.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42,43 Linkage is a creditable organisation that is well run and managed from the top down, with a wide range of policies and procedures that are regularly reviewed and monitored which promote service users rights and best interests. Service users live in a safe environment however all staff need to be up to date with mandatory training. EVIDENCE: Staff spoken to stated that the registered manager is “friendly and very easy to talk to” and another said she is “superb, if she doesn’t know the answer she will find out”. The manager has worked for Linkage since 1998, She has undertaken various training courses in working with people with learning disabilities and management training and has completed both NVQ level 2 and 3 and the assessors award. She is currently working towards the NVQ level 4 and the registered managers award. The Limes DS0000064078.V263086.R01.S.doc Version 5.0 Page 25 Regular staff and service users meetings are held and minutes were seen to confirm this. From examining the records the inspector was satisfied that Linkage had policies and procedures that covered a wide range of topics, were detailed and clear and gave staff clear guidance on how to conduct themselves. Staff spoken to could demonstrate their knowledge of the policies and procedures and how to implement them in practice. The policies and procedures were kept under review and a number had been updated and amended and new ones added. The Complaints procedure and fire procedure had been produced in a symbolised format and provided in a DVD. Linkage have a Corporate Quality Monitoring system (EFQM) and a Quality Manager who co ordinates and leads on quality issues. A year long calendar is produced that provides the framework for QA activity including surveys, audits and appraisals. Comment cards had been translated into makaton symbols to aid service users understanding and enable them to participate in the process. Linkage produces an Annual Review document and regular newsletters. The home had a signed written statement of the policy, organisation and arrangements for maintaining safe working practices. Staff need to complete all mandatory training. The home had a policy and procedure for infection control. Training records showed that all staff had received basic first aid training and two staff to the level of ‘appointed person’. A first aid box was kept at the home. Moving and handling assessments had been completed for each service user. Evidence from policies and procedures, staff training records, risk assessments and discussions with staff demonstrated that the registered manager ensured as far as possible the health, safety and welfare of the service users. Individual risk assessments were completed for service users and environmental risk assessments were also in place. A record of accidents to staff and service users was kept and seen at inspection. All required maintenance and servicing had been carried out to the required level. The Limes DS0000064078.V263086.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 4 2 3 4 3 Standard No 22 23 Score 4 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 4 4 4 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 4 4 4 4 4 4 4 LIFESTYLES Standard No Score 11 4 12 4 13 4 14 3 15 3 16 4 17 Standard No 31 32 33 34 35 36 Score 3 2 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Limes Score 3 4 4 x Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 2 4 DS0000064078.V263086.R01.S.doc Version 5.0 Page 27 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. 1 Standard YA2 Regulation 14 Requirement Timescale for action 07/11/05 2 YA32 18 3 YA37 9 4 YA42 18 The registered person must ensure that they obtain a copy of the single care management assessment and care plan prior to admission. The registered person must 31/03/06 ensure that at least 50 of the care staff are qualified to NVQ level 2. The registered person must 31/12/05 ensure that the registered manager has competed the NVQ level 4 in care and the Registered Manager’s award. The registered person must 31/03/06 ensure that all staff receive mandatory training and that this is kept up to date as required. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Limes DS0000064078.V263086.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Limes DS0000064078.V263086.R01.S.doc Version 5.0 Page 29 - 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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