Care Home: 74 Lifstan Way

Similar services:

• Chesham House
• Argyll House
• Dorset Lodge
• Acacia House
• Dial House Nursing Home
• Cromwell Avenue (9)
• Abbey Lodge

What the care home does well People living at Lifstan Way are happy there and made positive comments such as, "The time has gone quickly as I am so happy living here." People are encouraged to be independent, and fully involved with all aspects of planning for, and reviewing their health, care and lifestyle needs. People are consulted about their life in the home and their views taken into account.Staff are experienced, and most have worked at Lifstan Way since it reopened after refurbishment approximately eighteen months ago. This provides consistency for people. What has improved since the last inspection? A new full time and permanent manager has been in post since January this year. They have been encouraging people to enrich their lifestyle by trying different activities. People have always made good use of the local community, but this is now being enhanced by links being made with the local school, and hopefully in the future other community groups. People living at Lifstan Way, now have allocated community workers that they and staff at the home can liaise with quickly if there are any concerns about their health or wellbeing. Lifstan Way provides a modern and pleasant environment for people to live in. Since the previous inspection homely touches such as pictures, window dressings and flowers have been added to create a more homely feel. People appreciated this and felt that the home was warm and welcoming. CARE HOME ADULTS 18-65 74 Lifstan Way 74 Lifstan Way Thorpe Bay Essex SS1 2XE Lead Inspector Ms Vicky Dutton Unannounced Inspection 21st May 2008 08:30 74 Lifstan Way DS0000015445.V364869.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 74 Lifstan Way DS0000015445.V364869.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. 74 Lifstan Way DS0000015445.V364869.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 74 Lifstan Way Address 74 Lifstan Way Thorpe Bay Essex SS1 2XE 01702 466772 01702 613140 lifstanway@together-uk.org www.together-uk.org Together Working for Wellbeing 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) Manager post vacant Care Home 11 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (11) of places 74 Lifstan Way DS0000015445.V364869.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd July 2007 Brief Description of the Service: 74 Lifstan Way is a detached property, which has been refurbished to provide a good standard of accommodation. Personal care is provided for up to eleven adults with a mental disorder. Everyone currently living at Lifstan Way is over 65 years of age. The registration category does not include people who may have dementia or a learning disability. The premises are a two-storey detached house in a residential area situated in Thorpe Bay, Southend-on-Sea and is in close proximity to local community facilities and transport links. The accommodation provides single bedrooms, each with its own wash hand basin, shower and toilet en suite facilities. In addition, there is a separate communal lounge and dining room, kitchen, toilets and bathroom facilities. A shaft lift is available which serves all floors. The home is located in a residential area close to the local shops and bus routes. People have the use of a medium-sized garden/patio area. Limited car parking space is available. The current standard rate of fees is £865.00 per week. This figure can vary for individual people depending on the arrangements agreed with funding authorities. Additional charges are made for hairdressing, toiletries & chiropody. A statement of Purpose and Service Users Guide are available. A copy of the most recent inspection report is on display for people to read. 74 Lifstan Way DS0000015445.V364869.R01.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. This was an unannounced ‘key’ site visit. At this visit we (CSCI) considered how well the home meets the needs of the people living there, how staff and management work to provide good outcomes for people, and how people are helped to have a lifestyle that is acceptable to them. The level of compliance with requirements made at the previous inspection was assessed. The site visit took place over a period of six hours. A partial tour of the premises was undertaken, care records, staff records, medication records and other documentation were selected and various elements of these assessed. Time was spent talking to, observing and interacting with people living at the home, and talking to staff. A staff handover was attended. Shortly following the site visit the home’s Annual Quality Assurance Assessment (AQAA) was sent in to us (CSCI.) The AQAA was received before the due date and outlined how the home feel they are performing against the National Minimum Standards, and how they can evidence this. Before the site visit a selection of surveys with addressed return envelopes had been sent to the home for distribution to residents, relatives involved professionals and staff. The views expressed at the site visit and in survey responses have been incorporated into this report. We were assisted at the site visit by the manager, and other members of the staff team. Feedback on findings was provided to the manager throughout the inspection. The opportunity for discussion or clarification was given. We would like to thank the manager, staff team, residents, relatives and visiting professionals for their help throughout the inspection process. What the service does well: People living at Lifstan Way are happy there and made positive comments such as, “The time has gone quickly as I am so happy living here.” People are encouraged to be independent, and fully involved with all aspects of planning for, and reviewing their health, care and lifestyle needs. People are consulted about their life in the home and their views taken into account. 74 Lifstan Way DS0000015445.V364869.R01.S.doc Version 5.2 Page 6 Staff are experienced, and most have worked at Lifstan Way since it reopened after refurbishment approximately eighteen months ago. This provides consistency for people. What has improved since the last inspection? What they could do better: People living at Lifstan Way are fully involved in planning for their care. However care plans have not always been updated when needed to reflect people’s current needs. This could affect care outcomes if staff are unaware of any changes in people’s health or care needs. Although medication is generally managed in ways that keep people safe, some improvements to practice are needed. Staff training in medication procedures also needs to be reviewed to make sure that staff are up to date and have good knowledge and skills. When staff are recruited, information and records to show that this has been done in a safe and satisfactory manner, need to be available in the home. This is necessary to demonstrate that people are being protected and that Regulations are being complied with. So that staff are up to date in their knowledge, and to assist them in reacting appropriately to any situation, they should have access to up to date policies and procedures. 74 Lifstan Way DS0000015445.V364869.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. 74 Lifstan Way DS0000015445.V364869.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 74 Lifstan Way DS0000015445.V364869.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, 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People wishing to move into the home know that they will be at the centre of the decision making process, and that they will be offered a place based on an assessment of their needs. EVIDENCE: There is a Statement of Purpose and Service Users Guide in place to provide people interested in moving to the home with information. These could not be accessed on the day of the site visit due to a computer issue, but were sent to us (CSCI) following the inspection. People who have previously moved in felt that they had received enough information to help them to make an informed choice. There have been no admissions to the home since the previous inspection. The manager explained the admission process, including assessments. People who had previously moved into Lifstan Way said that they had been offered opportunities to visit and stay at the home before moving in. One said, “I was at **** for two and a half years then came here. I tried it for a weekend I liked it so they said I could stay,” and another, “I came to look around and it was alright.” Surveys were returned by five of the seven people living at Lifstan Way. All said that they had been offered a choice about moving into the home. 74 Lifstan Way DS0000015445.V364869.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People will be consulted about their care needs and encouraged to say how these should be met. They will be encouraged and supported to make choices in their daily lives. EVIDENCE: Each person has a care file in place containing care plans. Three care files were viewed as part of this site visit. People living at Lifstan Way are very much involved in planning their care and deciding how they want to live. Care plans reflected their needs and choices. People are involved care planning and had signed to say that they agree with the plans in place. A monthly evaluation and review takes place. This is undertaken by the person and their key worker. The evaluation provides a summary of the months events and notes any changes to, for example, medication or care needs. Care plans in place dated from February 07. In some cases people’s needs had changed, with changes reflected in other records, but the care plans themselves had not been updated. The manager said that at the moment everyone is going 74 Lifstan Way DS0000015445.V364869.R01.S.doc Version 5.2 Page 11 through a formal annual review process with the involvement of relevant professionals, and that following this, the care plans will be re-written as necessary. Evidence of this review process was seen on files. People are encouraged to make choices in their daily lives. As observed at the site visit, when support is needed to assist in decision making this is done in a sensitive manner. One person said, “We have freedom. I have freedom, my freedom to do the things I like. Told to treat it as my home,” another said that they made their own decisions, “Unless I am very unwell, then I ask the staff what they think.” Records showed that regular meetings take place on both an individual and group basis where people can talk about their needs and preferences. Risk assessments were in place relating to relevant areas of individual need. Again these had been fully discussed with the person concerned, and where necessary advice sought from other professionals. Risk assessments had been regularly reviewed to ensure that they were still relevant and current. 74 Lifstan Way DS0000015445.V364869.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People will enjoy a lifestyle that suites their individual needs and preferences. EVIDENCE: People living at Lifstan Way are supported in pursuing social and recreational activities in accordance with their individual needs and choices. Some attend local day care facilities. Others prefer their own company and follow their own routines. Activities take place in the home. Recently the manager has been arranging a series of ‘taster sessions’ to encourage people to think about undertaking other activities and see which are preferred. One said, “We had good music…... football, the craft day was good. We had a good time with Easter Bonnet day and wellbeing week.” Tai chi, belly dancing and health and beauty sessions had also been enjoyed. A talk from a local voluntary services organisation had been arranged to increase people’s knowledge of the sorts of services, facilities and opportunities that might be available to them. People 74 Lifstan Way DS0000015445.V364869.R01.S.doc Version 5.2 Page 13 also said that they liked getting out and about, and had enjoyed a recent theatre trip. Greater involvement with the local community is being encouraged, and good links have been built with the local school. Children from the school enjoyed joining people at the home for a coaching session from the local football team, and people living at Lifstan Way have been invited to events at the school. People at the home make full use of local community shops and facilities. Care files included care plans relating to relationships. These showed that people are supported to maintain links with people that are important to them. As seen at the site visit, and noted in documentation people can welcome friends into the home, and can visit them in return. One person said that they could have visitors at any time. The manager said that everyone holds their own front door key, room key and key to lockable storage in their room. During the site visit people used all areas of the home as they wished. People’s privacy and choices were respected. People are encouraged in accordance with their individual needs, and with support where necessary to undertake some household tasks. One said, “I help to do the vacuuming,” and another that the cleaner helped them to clean their room. People spoken with said that they enjoyed the food, and were offered choice. A four weekly menu plan is followed. This is changed according to season and people’s comments and choices. When viewed menus showed that a good variety of foods are offered. Fresh fruit was readily available for people in the lounge and dining areas. One person said that the food was “always very nice.” 74 Lifstan Way DS0000015445.V364869.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People will be able to access good healthcare support to meet their individual needs. EVIDENCE: Observations at the site visit, and people spoken with showed that people felt confident with the way staff interact with and support them. The manager said that they always tried to staff the home so that there was a choice of male or female staff available to assist people. On the day of the site visit a person attending the doctor’s surgery was asked who they wished to go with them. One person spoken with felt well supported and said, “They look after you very well here.” Personal care records sampled, confirmed that people had been involved in discussing their health needs and how these should be addressed. Records showed that referrals were made to other professionals, and that people are supported to attend hospital and other appointments when needed. Since being in post the manager has ensured that everyone has a community psychiatric nurse and care co-ordinator involved with their care so that any 74 Lifstan Way DS0000015445.V364869.R01.S.doc Version 5.2 Page 15 deterioration or concern can be quickly addressed. The manager said that regular ‘networking’ meetings take place with involved professionals, to maintain good communication. A visiting professional felt that staff had the right skills and supported people to live the life they chose. No one living at Lifstan Way takes full responsibility for managing their own medication. People had signed to say that they agreed to staff assisting them with this. Some people sign for their own medication when they have been supervised in taking it. Although the system was generally well managed, and good information was available to staff about medications and possible side effects, some practice issues were highlighted to management. This included the need to ensure that any handwritten entries were double signed to show that the information had been checked, and the need to ensure that instructions for the administration of medicines are always clear. In one case the medication was recorded by the pharmacist as to be taken ‘as and when required,’ (PRN,) when in fact staff said the doctors instruction was for the medicine to be taken on alternate weeks. Although there was a list of PRN medicines held in the home, there were not protocols for the administration of these in relation to individual needs available. It was stated that medication training is due to be updated. On the training matrix only four staff are recorded as having undertaken medication training, one in 2007, two in 2005 and one in 2004. Staff confirmed that training undertaken had been the basic level provided by the supplying pharmacist. The manager said that she was attending medication training, provided by the organisation on the day following the site visit. 74 Lifstan Way DS0000015445.V364869.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. People will have access to a clear complaints procedure, and be safeguarded from abuse. EVIDENCE: People are aware of how to raise any concerns and know who they should speak to. People said that they would always speak to the manager or senior staff, and were aware that they could also contact the organisations area manager. The home’s complaints procedure needs some updating to make people aware that CSCI no longer investigate specific complaints about a service, but that people can raise any concerns through the local authority funding their placement. No complaints had been recorded and a complaints recording system could not be found. Later a complaints recording form was found within the organisations policies book, and a file set up for recording any future complaints or concerns. A ‘Minor Complaints’ book was also found. The home has satisfactory policies and procedures in place to safeguard people from abuse. Staff have received training in safeguarding adults, and a safeguarding training pack is available in the home. To provide clearer information for staff, during the visit the manager found out the contact details for the local safeguarding team and made these details readily available for staff. 74 Lifstan Way DS0000015445.V364869.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, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a pleasant and clean home. EVIDENCE: Lifstan Way provides people with a bright and pleasant place to live. Since the previous inspection more homely touches have been added. One person said, “The decoration and flowers are nice. The atmosphere is lifted. It looks nice.” People spoken with said that they liked the home. One said, “I have a lovely room and my own bathroom.” On the day of the site visit the home appeared fresh and clean. On surveys people said that this was always the case. One said “We have a cleaner every day. They helped me to clean my room. That was good,” and another, “Yes really clean and the flowers look nice. Very pleased with the cleaner and everyone works hard.” There is a suitable laundry area. Training records showed that staff have received training in infection control. This will ensure that good practice is maintained. 74 Lifstan Way DS0000015445.V364869.R01.S.doc Version 5.2 Page 18 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. 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 experienced and trained staff. EVIDENCE: People spoken with were very happy with the support they received from staff. One said, “It is a friendly home. The staff are friendly and I have fun and a joke.” Of the home’s eight permanent senior and social care workers five have completed a National Vocational Qualification in care at level three. This will enhance their knowledge and skills. Most staff at Lifstan Way have been in care work for a number of years and have the experience and training to meet people’s needs. The home’s training matrix and staff files showed that as well as receiving training in core health and safety areas, other training relevant to the needs of people living at the home is undertaken. This included training in diabetes and The Mental Capacity Act. The organisation produces an annual training manual and staff can apply for courses relevant to their needs. Staff spoken with felt that there were good training opportunities available to them. 74 Lifstan Way DS0000015445.V364869.R01.S.doc Version 5.2 Page 19 Although registered to provide accommodation for eleven people, on the day of the site visit six people were being accommodated, (with a seventh person currently away.) The home’s rotas showed that basic staffing levels are being maintained as two staff on each shift during the day and one sleeping in member of staff at night. On some days more staff are available. The manager’s hours are supernumerary during weekdays. Chef and domestic hours are provided during weekdays. The manager is aware that staffing levels, particularly at night will need to be kept under review when more people move in, or if the needs of people living at the home change. No new staff, apart from the manager, have started working at Lifstan way since the previous inspection. Existing staff files, and discussions with the manager confirmed that all appropriate checks are carried out before people commence work. A cleaner has recently been recruited and the manager said that they were waiting for the return of a satisfactory Criminal Records Bureau check before they could be offered a start date. The manager said that all information is collated at head office and then the file is sent to the home. However the manager has been in post since January and their file was not available. It was confirmed that people living at the home would meet potential new staff when they visited, show them round and think of any questions they wished to ask. A staff survey said that all aspects of recruitment were done properly, and that an induction programme covered everything needed. The manager confirmed that an initial induction checklist is completed and that new staff would undertake an induction based on Skills for Care Standards. New members of staff also attend a two day induction programme at the organisations head office. 74 Lifstan Way DS0000015445.V364869.R01.S.doc Version 5.2 Page 20 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, 40, 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a safe and well managed home. EVIDENCE: Since the previous inspection a full time manager has been appointed at Lifstan Way. They have been in post since January, and plan to commence the Registered Managers Award later this year. Although experienced in different areas, their previous working experience has not been specifically in mental health. Feedback about the manager from people living in the home was positive. One person said “[the manager] is very good and has arranged a lot of different things.” The organisation strategies in place to monitor the quality of the service offered at Lifstan Way. An annual review of the service is undertaken which incorporates the use of questionnaires for people using the service and other 74 Lifstan Way DS0000015445.V364869.R01.S.doc Version 5.2 Page 21 involved people. Open forums are also held where people can express their views. Records showed that the last review took place in September 2007. Monthly visits, as required by Regulation, are undertaken by a senior manager to ensure that the service is running in line with standards and Regulations. Records showed that these are undertaken in a thorough way, and include talking to people who use the service. Regular feedback is sought through meetings with people using the service and staff. The home’s AQAA was received before the due date. This showed that the home recognise where improvements to the service can be made and plan to achieve these. From the AQAA it was noted that many of the policies and procedures in place have not been reviewed for a number of years. This needs to be addressed by the organisation to ensure that staff are following up to date practices. The home’s AQAA showed that services and systems are checked and maintained. No health and safety issues were noted during the site visit. So that people are cared for safely regular checks of safety equipment are undertaken. The home consults with the fire service and have a risk assessment in place. Training records showed that staff receive a good level of training in areas relating to health and safety such as risk assessments, first aid, fire prevention, and moving and handling. 74 Lifstan Way DS0000015445.V364869.R01.S.doc Version 5.2 Page 22 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 X 3 3 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 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 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 2 X 2 X 3 2 X 3 X 74 Lifstan Way DS0000015445.V364869.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement So that people living in the home are cared for safely, their medicines must be managed properly at all times by well trained and competent staff. Staff must receive good training and have their skills in managing and administering medication regularly monitored and assessed. The practice issues identified in the body of the report must be addressed. People must be confident that they are protected by safe recruitment practices being maintained. Records relating to staffs’ employment must be available for inspection. Timescale for action 01/06/08 2. YA34 19 (1) (b) 01/06/08 74 Lifstan Way DS0000015445.V364869.R01.S.doc Version 5.2 Page 24 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 YA40 Good Practice Recommendations So that staff practice is based on up to date information, policies and procedures used to ensure the correct running of the home should be kept under regular review. 74 Lifstan Way DS0000015445.V364869.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 74 Lifstan Way DS0000015445.V364869.R01.S.doc Version 5.2 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!