Care Home: 21 Lime Street

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What the care home does well People have a varied lifestyle which helps them to take part in activities and build relationships People`s needs are met by having good care plans which they are fully involved in making The staff are well trained and know how to meet people`s needs The house is homely and there is a relaxed and welcoming atmosphere What the care home could do better: People should have their essential lifestyle plan reviewed more often People`s key workers should make sure all the information is passed on from outside people such as advocates The manager should keep the complaints and other incidents together so that he can keep an eye on what happens in the house. CARE HOME ADULTS 18-65 21 Lime Street Evesham Worcestershire WR11 3AW Lead Inspector Emily White Unannounced Inspection 12th September 2008 09:00 21 Lime Street DS0000069582.V371794.R03.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 21 Lime Street DS0000069582.V371794.R03.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. 21 Lime Street DS0000069582.V371794.R03.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 21 Lime Street Address Evesham Worcestershire WR11 3AW 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) 01386 422 017 www.noblecare.co.uk Noble Care Ltd Mr Martin William Crookston Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 21 Lime Street DS0000069582.V371794.R03.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide personal care and accommodation for service users of both sexes between the age of 18 and 65 whose primary care needs on admission to the home are within the following category: Learning Disability (LD) 8 The maximum number of service users to be accommodated is 8 2. Date of last inspection 7th November 2007 Brief Description of the Service: 21 Lime Street is a residential care home in Evesham, which provides specialist support for up to eight people with a learning disability and associated behaviour, which challenge the service. The home is a spacious home, which offers single bedroom accommodation and is close to Evesham town centre. The registered provider is Noble Care Limited. The registered manager is Mr Martyn Crookstone. Information about fees can be obtained from the service. 21 Lime Street DS0000069582.V371794.R03.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The manager, Mr Crookston sent information about the house to us before we visited. Seven people who live at the house sent us surveys, and six people who work there sent us surveys. We visited on a week day, and the manager was on duty and helped us. We met five people through the day who showed us around their home and talked to us about their home. We met some members of staff who were on duty. We looked at some records such as care plans and medication and looked at how the house is run. What the service does well: People have a varied lifestyle which helps them to take part in activities and build relationships People’s needs are met by having good care plans which they are fully involved in making The staff are well trained and know how to meet people’s needs The house is homely and there is a relaxed and welcoming atmosphere 21 Lime Street DS0000069582.V371794.R03.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 21 Lime Street DS0000069582.V371794.R03.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 21 Lime Street DS0000069582.V371794.R03.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People moving to the service have good information to use to help their decisions. People have a full assessment of their needs and can visit the service beforehand, so they can be confident the service can meet their needs. EVIDENCE: There have been no new people who have moved to the service and everyone who lives there plans to stay for the long term. We received seven surveys from people using the service who all said that they had enough information and had chosen to move there. The manager has developed an audio guide for people moving to the service which provides accessible information. Other services run by Noble Care currently have new people moving in, and a new assessment has been developed for all of the services. This has not yet been used at 21 Lime St. The service is well prepared, should vacancies arise, to help people make the decision about whether the home would be right for them. The Annual Quality Assurance Assessment tells us that people are able to visit before they make a decision and their suitability and compatibility is considered with people who already live there. 21 Lime Street DS0000069582.V371794.R03.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported through good care planning and by staff who know them well. People are able to make decisions and take risks in their daily lives which help them stay independent. EVIDENCE: During our visit we looked at two people’s care plans in detail, and another two in less detail. People using the service have a detailed care plan, a health action plan, and an essential lifestyle plan which is their personalised plan. Everyone has an allocated key worker who knows their care needs very well. Notes from key worker meetings show that the care plan is reviewed every two or three months. These reviews are detailed and cover many aspects of people’s lives for example behaviour, communication, mental health, daily living, activities, and medication. The review notes show that changes are being followed up and people are developing, for example, going to college and changes to levels of supervision. 21 Lime Street DS0000069582.V371794.R03.S.doc Version 5.2 Page 10 The key workers use the health action plan, people’s daily activity checklist, their personal diaries, and mood monitoring charts to help them with the review. Some people’s plans have individual ways of monitoring behaviour, which are set up when needed at particular periods in people’s lives. These might look at mood and behaviour, and incident recording. A full care plan and health action plan review takes place annually. Two of the care plans we saw had been reviewed in June and July of this year. We were not able to see whether people’s essential lifestyle plans had been reviewed, and one person’s had a date of 2006 written on it. The essential lifestyle plan is people’s main way of understanding their care needs. It is written from the person’s viewpoint, and covers areas such as “my positive reputation”, “what is important to me”, “what I enjoy”, “what is working now”, “what needs to change”, and “what others think are important - I may or may not agree”. One person we spoke to was able to show us his essential lifestyle plan, which also contains photographs, personal details, certificates, and risk assessments. The essential lifestyle plan is a good example of person centred (individual) working, and it is important that it is updated on a regular basis. The essential lifestyle plan and key worker system also helps people with decision making about how they want to progress. People are fully involved in their key worker reviews and sign at the bottom to show this. One person told us that his key worker review is “hard work, we talk about how I’ve progressed and what’s changed”. Another person told us “I like my key worker; they help me to do exactly what I like”. Seven people sent us surveys which told us that they can always make decisions about what they want to do, during the day, evening and weekend. People have individual activity timetables up on the wall – these are decided by people on a daily basis. People also have the opportunity to go to residents meetings which happen roughly quarterly. The manager tells us people do not want them more often than this as it can be a stressful event for some people. The service has also made good use of advocacy to assist in resolving a concern between two people in the house. People have detailed individual risk assessments in each care plan, for example being able to go out to certain places unaccompanied. These risk assessments are signed and agreed by the person to show they understand and commit to whatever has been agreed. The risk assessments demonstrate that people’s requests for changes and development are listened to and acted upon appropriately. It is important that the risk assessments are reviewed regularly, which the service has already identified as part of a recent audit. 21 Lime Street DS0000069582.V371794.R03.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People lead a full and varied lifestyle that meets their needs and wishes. People are supported by staff in meaningful occupation, taking part in the daily routines of the house and enjoying meals that they prepare. People maintain relationships outside of the service. EVIDENCE: We spoke to five people using the service during our visit. One person told us about his part time job helping in a charity shop. Two other people have been enrolled in college for the new term. From people’s activity chart and daily checklist we can see that people also go to day centres, take part in activities such as cookery at home, and use the internet. People’s essential lifestyle plans show certificates and photographs of their achievements in the past year. The manager tells us that not everyone is able to go to college or get a job and other learning and development is supported at home through daily tasks, cookery, photography, and use of the internet. 21 Lime Street DS0000069582.V371794.R03.S.doc Version 5.2 Page 12 The service runs a system of therapeutic earnings for jobs completed around the house. People also have opportunity for holidays, for example some people were in Spain during our visit. People make use of local facilities, for example most people were out at the start of our visit. People use local shops, library, cinema, pubs, in Evesham some residents are well known in the local town. Key worker’s time is spent enabling people to access the local community, however the Annual Quality Assurance Assessment recognises that improving social contacts in the community and developing a better community presence is important. People have contact with their families, which is set out in their care plans. One person told us he had been speaking to his mum and he goes out and about with his brother regularly. People are able to develop their own personal relationships outside of the house, and receive support from the service to develop and maintain relationships according to their care plan. People’s bedrooms are very personalised and clearly treated as their personal areas. One person has a key to his room but others do not. Rooms can be locked from the inside but this can be overridden from outside. People do not have access to private lockable storage in their rooms. We observed staff having appropriate interactions and banter with people in the house, and observed people assisting with household tasks such as washing up after the evening meal. Staff and people using the service report that they each cook once a week and often help plan meals and do the shopping. Menus are recorded in ways that people can understand, and choice is offered. During our visit we saw that the food looked appetising, this was cooked by a staff member on this day. Everyone we spoke to during the day said they like the food. One person who sent us a survey wrote that: “It is a nice place to live and the food is great, the manager is fantastic, my friends at Lime Street are very good friends. I like all staff in Lime Street. Very pleased I came to the home. I also like to do some office work in the home and I get on very well”. 21 Lime Street DS0000069582.V371794.R03.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s health needs are met through care planning and by staff who support them. EVIDENCE: We looked in detail at two people’s care plans, and two others in less detail. These records show that very few people have support with intimate personal care. Most people have support for management of stress, behaviour that might challenge others, and money, medication, and lifestyle. The service has an experienced registered mental health nurse who works for Noble care and can assist with management of complex behaviours. For example one person has very detailed guidelines for staff on how to approach him at challenging times. Training records also show us that staff have had individualised training focused on individual needs to help their understanding of some people’s behaviour. We received seven surveys from people using the service, who all tell us that staff always treat them well, and that staff always listen and act on what they say. The records give very detailed information about people’s preferences for support and are reviewed annually and through key worker meetings. Staff 21 Lime Street DS0000069582.V371794.R03.S.doc Version 5.2 Page 14 complete a daily checklist of what the person has done that day, and a personal diary at the end of the day which records mood, activities, medications, and the food they have eaten if this is relevant to the care plan. These records are up to date and show that people are living as suggested by their care plans and activity sheets. People’s health action plans contain information “about me”, emergency details, communication, medication, and all aspects of health. They record the next appointments due for health checks such as the dentist, with space for recording the outcome. This is fed into the care plan by the key worker at the review. Use of communication books and staff handovers also ensure information is passed on. For example we saw that advice from a doctor to help someone manage their weight was being monitored through the health action plan and through the key worker notes. The person concerned told us he has been eating more salad recently and likes salad. Records show that one person’s visits to his doctor are six monthly as advised in the care plan. However involvement of other outside professionals such as advocates is less well recorded. The care plans contain letters from GPs, and occupational therapists at the front. These could be filed more systematically to ensure communications from outside health professionals are not missed. To ensure that the flow of information is up to date it would be good practice for key worker meetings to take place more regularly than records show at present. Everyone who uses the service currently receives help with their medication. There are clear guidelines for staff for medications that are given “as needed” to prevent people from taking too many. The service has set up a “homely remedies” policy for each person as a result of an audit. We observed staff taking medications from a cabinet and prompting people appropriately. A new medications cabinet is in place following the last inspection. Medications recording is generally in good order however there was one incomplete record where medication had been given but not signed for. A new medication cabinet is in place following the last inspection. The Annual Quality Assurance Assessment identifies an area for improvement is to try to support people to take more responsibility for their own health – more frequent key worker meetings may assist with this. 21 Lime Street DS0000069582.V371794.R03.S.doc Version 5.2 Page 15 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. People are protected by a robust policy and staff who are well trained. People know how to complain and know that their concerns will be addressed quickly. EVIDENCE: The manager has recently developed a new complaints form which is written in easy to read language and pictures. One person using the service made use of the complaints procedure, which lead to the service sending notifications to CSCI and to a safeguarding meeting lead by social services. Following concerns that the service was not managing this process very well, the service has made some improvements. In relation to this particular concern, the service was able to report on what actions had been taken, for example employing an advocate. Complaints are kept in people’s essential lifestyle plans with letters from the manager showing how these have been followed up. There is a communal table which gives access to the complaints form and the CSCI report and other relevant contact information. We received seven surveys from people using the service, all of which said that they know who to speak to if they are not happy, and they know how to complain. We also received six surveys from staff, who all said that they know what to do if there are concerns relating to anyone using the service. All staff have had protection of vulnerable adults training in 2007 or 2008, and three staff have had training in managing challenging behaviour. We spoke to staff who said that they understand the process to follow if there is a concern. 21 Lime Street DS0000069582.V371794.R03.S.doc Version 5.2 Page 16 The requirement from the previous inspection to make arrangements to safeguard people using the service has been met. However it would be good practice to record all complaints, notifications to CSCI, incidents and safeguarding action in one place so that the manager can clearly monitor complaints and protection for the whole service. 21 Lime Street DS0000069582.V371794.R03.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, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements have been made to the home environment and people now live in a safe and comfortable house with appropriate facilities to support an active life. EVIDENCE: The house is close to the local facilities in Evesham and these are used by everyone. Since the last inspection the interior has been updated and is homely and comfortable. During a random inspection the service was able to demonstrate that it has put in place a maintenance matrix, risk assessments, and a health and safety agreement for workmen. A tour of home showed it to be in an improved condition. People’s rooms are personalised and very comfortable. People tell us that they have felt safe during the refurbishments. All requirements have been met in this area following an improvement plan by the service. The Annual Quality Assurance Assessment tells us that a new monitoring system of audits includes the environment and hygiene. During our visit we 21 Lime Street DS0000069582.V371794.R03.S.doc Version 5.2 Page 18 observed that procedures are followed to maintain hygiene and control of infection, for example staff wearing gloves when they administer medication. The house was pleasant and smelled fresh. People tell us that they assist to keep their bedrooms and other areas of the house clean and tidy, and all surveys we received say the house is always fresh and clean. 21 Lime Street DS0000069582.V371794.R03.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, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported by a well trained staff team who are knowledgeable in their area of work. People can feel safe that staff have had background checks and are well qualified to carry out their jobs. EVIDENCE: We received six surveys from staff, who told us that they always have the right support, experience, and knowledge to carry out their jobs. The manager has set up a training matrix which shows that staff are being booked onto NVQ training levels 2 and 3. We spoke to a new member of staff who told us she is being supported to do NVQ 2. The ANNUAL QUALITY ASSURANCE ASSESSMENT tells us that 80 of staff hold NVQ2 and others are training. A learning culture is supported by the manager and deputy manager. People tell us that they like and trust the staff and get on well with them. Everyone says they like their key worker. The staff surveys also tell us that staff are receiving relevant training to their jobs which helps their understanding and keeps them up to date. The training matrix shows staff have had all mandatory training as well as client specific training. Some staff have had training in the mental capacity act, challenging 21 Lime Street DS0000069582.V371794.R03.S.doc Version 5.2 Page 20 behaviour and relationships and sexuality. We spoke to staff who said they have had excellent training, and new staff tell us they have had an induction and felt able to do their jobs. Two staff who sent surveys said that their induction covered everything very well and four said that it mostly covered everything. One staff member wrote “good thorough induction from manager and deputy within the home”. The manager has started to use the Skills for Care induction package which shows an improvement in the way staff inductions are carried out at the service Surveys received from staff tell as that they had all the appropriate background checks before they started work. We looked at three staff files which all had the correct criminal records checks. Only one new staff member had one reference missing. The manager is aware of this and explained that the reference is expected from a college tutor who has not returned from holiday yet. The manager is aware that he should ask for another reference if this one does not arrive. In some staff files the records of start dates were not clear. This is good practice allowing the manager to monitor references, training and development needs of staff. Three of the staff surveys we received said that they have meetings with their manager regularly, and three said often. One staff member wrote “very good support from management”. The manager tells us that regular supervision is an area for improvement. The supervision notes file shows that staff had supervision in July, however previous dates show that it is not regular and some people had not had supervision for several months. 21 Lime Street DS0000069582.V371794.R03.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. Improvements have been made to the management of the service and people are now supported by a service that is managed well and safely. People’s opinions are included in developing the service and records are kept to show how improvements are being made. EVIDENCE: We received many positive comments from people using the service and staff during our visit and from surveys. Staff who sent in surveys tell us that they always have up to date information, passing on of information works well and there are usually enough staff working. Staff have a communications book and have long staff handover meetings at change of shift. There are roughly 5 staff meetings per year at key points during the year e.g. holiday seasons. The manager tells us there has been some short staffing which has been covered by overtime. He has recruited a new staff member and was holding interviews 21 Lime Street DS0000069582.V371794.R03.S.doc Version 5.2 Page 22 at the time of our visit. Staff tell us that the service “supports people to live their lives”; and “gives people choices, respects people, overall a good service is provided”. The requirement to have sufficient management time provided and protected has been met. The manager now works supernumerary which has given much more time for management work. This was shown by the new management system in the office which was very clear and easy to locate information in his absence. The home has recruited several new staff and a deputy manager which allows freedom for the manager. The Annual Quality Assurance Assessment is very detailed and tells us all the information we need to know about all the standard of the service. It shows there has been a lot of improvement and that the service is aware of further areas for improvement. There is a new system for measuring the quality of the service. This includes surveys from family and health professionals as well as people using the service. All comments so far have been positive. The surveys are used to write a report. The provider has carried out three audits since November 2007 which has also helped to identify areas for improvement, which is shown by the action plan from their last audit. To assist this process it would be good practice for complaints, notifications to CSCI, and incidents to be collected together in a way that helps the manager to monitor them. The manager has a checklist for those responsible for health and safety checks which include himself and senior staff. Health and safety checks are carried out monthly. Environmental risk assessments have been completed and will be ongoing. The training matrix shows that all staff have had mandatory health and safety training which meets a requirement from the last inspection. 21 Lime Street DS0000069582.V371794.R03.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 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 X X 3 X 21 Lime Street DS0000069582.V371794.R03.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. 1 Standard YA34 Regulation 19 Requirement The service must ensure that all staff have two written references and have completed all necessary checks prior to employment. Timescale for action 30/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations The essential lifestyle plan should be updated alongside the care plan, in keeping with person centred planning, so that people using the service have an up to date record they can use. The service should consider providing full training and support in person centred planning to all staff so that people who use the service know that their changing needs and goals are reflected in their plan. Risk assessments should be reviewed alongside the care plan, and dates recorded, to ensure they are up to date. DS0000069582.V371794.R03.S.doc Version 5.2 Page 25 2 YA6 3 YA9 21 Lime Street 4 YA16 Risk assessments should be carried out to explain why people do not have keys to their rooms. People should have the option to have access to private lockable storage if they wish. The service should consider the frequency of key worker meetings to ensure that information from outside professionals is not missed and to support people to take control of their own health needs. Recording of complaints and action taken should collected in one place to enable the manager to keep track and deal with people’s concerns efficiently Staff should receive regular supervision to enable them to support people who use the service as their needs develop Complaints, notifications to CSCI, and incidents should be collected together in a way that helps the manager to monitor them and keep people using the service safeguarded. 5 YA19 6 YA22 7 8 YA36 YA39 21 Lime Street DS0000069582.V371794.R03.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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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