Care Home: David Lewis Centre Frederick Harwood House

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What the care home does well The David Lewis Centre provides opportunities for people using the service to take part in activities around the centre to keep them active and stimulated. There are day services that anyone can attend and they can also travel to and from Macclesfield, depending on their medical condition. There is a consistent group of staff working at Frederick Harwood House who know the needs of the people using the service. This means that staff are aware of what to do when a person using the service suffers from a seizure. Several of the people using the services have 1 to 1 care according to their assessed needs to ensure that their needs can be fully met. The following comments were made on surveys received back before the site visit: `They give a very good service and the one to one care is what it says as whenever we visit the carer is always in my relative`s room.` `Excellent medical care` `The staff look after my relatives requirements admirably.`Staff are well supported in their training and have the skills and ability to conduct a series of investigations at the home to make sure that people using the home receive the correct care and treatment. There is a good recruitment procedure in place to ensure that staff employed are suitable to work with the people who use the service. What has improved since the last inspection? The physical environment has improved since the last inspection. Double rooms have been converted to single rooms so enhancing the privacy and dignity of the people using the service. The new conservatories and the newly decorated dining room provide a pleasant and comfortable place for people who use the service to use. The David Lewis Centre is working toward improving the management of medicines across the site so reducing any risk to people using the service. Fire safety procedures have improved. All staff have now had fire safety training and new door closures have been fitted, which enhances people`s safety. A training strategy for physical intervention of adults has been introduced across the site to make sure that staff have the skills to provide appropriate care in all circumstances. What the care home could do better: Care planning practices need to improve to make sure that all care plans are relevant and are up to date and accurate. Consideration needs to be taken on how people using the services can be actively involved in their own care planning process. Risk assessments for the use of bedside rails must be done before using this equipment to ensure that it is safe for the person to use them. CARE HOME ADULTS 18-65 David Lewis Centre Frederick Harwood House David Lewis Centre Mill Lane Warford Alderley Edge Cheshire SK9 7UD Lead Inspector Helena Dennett Key Unannounced Inspection 24 January 2008 10:00 David Lewis Centre Frederick Harwood House DS0000018770.V352050.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 David Lewis Centre Frederick Harwood House DS0000018770.V352050.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. David Lewis Centre Frederick Harwood House DS0000018770.V352050.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service David Lewis Centre Frederick Harwood House Address 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) David Lewis Centre Mill Lane Warford Alderley Edge Cheshire SK9 7UD 01565 640014 01565 640206 David Lewis Centre Mrs Gillian Dyson Care Home 29 Category(ies) of Physical disability (29) registration, with number of places David Lewis Centre Frederick Harwood House DS0000018770.V352050.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 29 service users suffering with a chronic physical disability and suffering from epilepsy. 9 August 2007 Date of last inspection Brief Description of the Service: The David Lewis Centre for Epilepsy opened in 1904. Its benefactor was the department store pioneer, David Lewis (1822-1885). The centre is set in 170 acres of land and has a village atmosphere. The facilities on site consist of a swimming pool, gymnasium, workshops, school college and social club. Frederick Harwood House, a single storey unit that comprises of four wings, is one of the original buildings of the centre. There are 29 single rooms with shared toilet facilities between each pair of rooms. Two rooms have en suite facilities. There is a large dining room and kitchenette and three separate lounge areas, one of which is designated for residents who smoke. There are also two conservatories. There is an enclosed garden and patio area. The residents’ primary needs are due to epilepsy and physical disability. The scale of charges range from £678 to £3241.45 per week. inspection report is available in the home. The latest David Lewis Centre Frederick Harwood House DS0000018770.V352050.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 stars. This means the people who use this service experience good quality outcomes. This unannounced inspection visit, which is part of the key inspection, took place over 6 hours. Before the visit the manager was invited to provide information about the home as part of this inspection process. The views of the people living in the home and their relatives were also sought and their comments are incorporated into this report. During the visit we spoke to the manager, some staff members and some of the people using the service. We looked in detail at the care records of three people who live at the home to check the care they receive. Records of medication, care plans and training was also examined as were some policies, procedures and paperwork used at the home. What the service does well: The David Lewis Centre provides opportunities for people using the service to take part in activities around the centre to keep them active and stimulated. There are day services that anyone can attend and they can also travel to and from Macclesfield, depending on their medical condition. There is a consistent group of staff working at Frederick Harwood House who know the needs of the people using the service. This means that staff are aware of what to do when a person using the service suffers from a seizure. Several of the people using the services have 1 to 1 care according to their assessed needs to ensure that their needs can be fully met. The following comments were made on surveys received back before the site visit: ‘They give a very good service and the one to one care is what it says as whenever we visit the carer is always in my relative’s room.’ ‘Excellent medical care’ ‘The staff look after my relatives requirements admirably.’ David Lewis Centre Frederick Harwood House DS0000018770.V352050.R01.S.doc Version 5.2 Page 6 Staff are well supported in their training and have the skills and ability to conduct a series of investigations at the home to make sure that people using the home receive the correct care and treatment. There is a good recruitment procedure in place to ensure that staff employed are suitable to work with the people who use the service. 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. David Lewis Centre Frederick Harwood House DS0000018770.V352050.R01.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 David Lewis Centre Frederick Harwood House DS0000018770.V352050.R01.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 People who use this service experience adequate outcomes in this area. We have made this judgement using available evidence including a visit to this service. Peoples’ needs are assessed before they come to the home so they can be confident their needs will be met. More needs to be done to make sure that people using the service have made a positive choice to live in Frederick Harwood House. EVIDENCE: Information about Frederick Harwood House is available but some of it is complex and may be difficult for people who use the service to understand. Since the last inspection there has been a change in the admissions policy for the home. Only people who need its specialist services are admitted and there is no longer an ‘acute’ bay for people living in other houses on the site to come in for short stays. There was evidence that one person had been admitted from another home on site for nursing/medical care. The manager said that as staff knew the service user, it was preferable that they were accommodated on Frederick Harwood House rather than in hospital. David Lewis Centre Frederick Harwood House DS0000018770.V352050.R01.S.doc Version 5.2 Page 9 One person who sent us a completed survey form before the site visit ticked ‘no’ to the question ‘were you asked if you wanted to move into this home’ and made the following comment: ‘I was put on here due to health issues’. During the site visit the manager arranged to visit a service user in hospital before they moved back to the home so that she could be confident that staff at the home were able to continue to meet this person’s needs. David Lewis Centre Frederick Harwood House DS0000018770.V352050.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 People who use this service experience adequate outcomes in this area. We have made this judgement using available evidence including a visit to this service. Care plans do not always reflect peoples assessed needs and so there is a risk that these needs may not always be met. EVIDENCE: Three people’s care records were looked at during this visit. Each of the records contained care plans, which should cover personal, social and healthcare needs. The care plans looked at did not cover all of the person’s needs. For example: it had been identified that one person had experienced considerable weight loss over a period of time, yet there was no care plan in place to identify what action staff and the person could take to address this issue. Some of the care plans were not evaluated so it was difficult to establish whether the care being delivered was effective. There was also some evidence David Lewis Centre Frederick Harwood House DS0000018770.V352050.R01.S.doc Version 5.2 Page 11 that people’s needs had changed but the care plan had not been updated to reflect this change. In one person’s records it was identified that they needed bedside rails to promote their safety. Although the bedrails were in use a risk assessment had not been completed to ensure that the equipment was suitable and safe for this person to use. There was little evidence presented to suggest that people living in the home take part in planning their own care as some of the care plans were written in medical terms and would be difficult for any person other than those from the medical profession to understand. Four people who use the home who sent us completed survey forms had answered ‘sometimes’ to the question ‘Do you make decisions about what you do each day’. The rest ticked ‘always’ to the same question. Information sent to us before the inspection visit suggests that staff at the home intend to incorporate the health action plan and the care plan, which will be easier to use and understand so service users can be fully involved in their care. The manager said that people living in the home were involved in decision making where possible. There was evidence in one person’s file that advocacy services had been sought. David Lewis Centre Frederick Harwood House DS0000018770.V352050.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 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People living in the home are able to maintain an appropriate lifestyle within their own limitations, therefore ensuring that their health and well being is maintained. EVIDENCE: The David Lewis Centre provides opportunities for people to take part in activities around the centre. There are day services that people can go to and people can travel to and from Macclesfield, depending on their medical condition. David Lewis Centre Frederick Harwood House DS0000018770.V352050.R01.S.doc Version 5.2 Page 13 Some people have timetables set up which clearly identify the activities they are going to do during the week. Staff at the home also arrange visits to pantomimes, shopping, bowling, the cinema and visits to local tourist attractions. It is the philosophy of the home that every client who is medically able should have the opportunity to go on holiday. In one person’s file it was recorded that they had been on holiday, although this consisted of one overnight stay with activities taking place during the day. One person’s care plan identified that they liked to go out and the planned action was to enable and support the person to go out every 1-2 weeks. The evaluation done in May 2007 identified that there would be an outing every week to different locations. There was evidence that the person was enabled to go out every fortnight. A review had taken place involving social workers, the person’s family and medical staff. Although minutes of the review were kept there was no evidence of the discussions between the commissioning body, the person using the service, relatives and staff to indicate whether they were satisfied with this arrangement. The following comments were made on relative survey forms received back before the visit: ‘A greater degree of social contact with people of my relative’s ability would be beneficial’ ‘Very good day services during the week’ One relative felt that people with communication difficulties were all sat together so reducing the opportunity for them to interact with others. Another relative said they felt staff do everything they can to help and assist their relative to use the telephone so that they can keep in contact. Mixed views were also received from staff surveys. One person felt the centre itself had good facilities for younger people, however more social stimulation was required in the home for the people living there as staff are busy carrying out caring tasks and don’t always have time to engage people in social activities in-house. Staff spoken with said that day services come in at weekend and provide massage therapy etc. Staff also assist people to bake, paint and take part in other activities according to their wishes. One of the people living in the home attends college regularly. People living in the home said they were satisfied with the care provided. One person indicated that they felt there was enough to do and that staff were good. David Lewis Centre Frederick Harwood House DS0000018770.V352050.R01.S.doc Version 5.2 Page 14 The appearance of the dining room has improved since the last inspection. New flooring, and new furniture and tablecloths have made it a more pleasant place for people to eat in. People living in the home are asked to make their choice of main meal two days in advance. Support with eating and drinking is given in a discreet way. David Lewis Centre Frederick Harwood House DS0000018770.V352050.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People who live at the home receive appropriate support so that their health and personal care needs are met. EVIDENCE: A lot of the people living in Frederick Harwood House have complex medical needs and require close observation of their condition. Several people have a carer on a 1 to 1 basis and are provided with the personal care needed. A concern was raised last year regarding the care of people’s feet. We carried out a short inspection at the home to look at this matter and found that people were adequately cared for, so the complaint was not upheld. A visiting healthcare professional spoke with us during the site visit. She said that she thought the care in Frederick Harwood House was good and people’s medical nursing and personal care needs were met. David Lewis Centre Frederick Harwood House DS0000018770.V352050.R01.S.doc Version 5.2 Page 16 The following comments were made on survey forms received back before the site visit: ‘Staff on the whole are really capable in their work. There is a good degree of happiness in those we do see. We feel that in everything the home tries to do it does a really good job’ ‘My relative is severely disabled and the staff at Frederick Harwood offer him excellent care. They look after all his requirements admirably – nursing, feeding, talking to him, looking to his interests.’ ‘Agency staff sometimes seems to lack the knowledge and skills required.’ Other professionals such as the dietician, physiotherapist and speech therapist assist people living in the home when necessary. A physiotherapist department is available on site and anyone who requires assistance can visit following assessment. There was evidence in one person’s file that an invasive procedure had been carried out even though there was no protocol in place for this procedure. The manager of the home agreed to investigate and inform us of the outcome of her findings. A medicine policy is in place and changes to the management of medicines are being implemented across the site. The medicine storage room needs attention; several tiles are missing from the wall and there has been a recent water leak. Two medicine trolleys are used. Although medicines are managed satisfactorily a small number of issues were noted. The date of opening was not identified for some eye drops which a limited shelf life once opened. A tablet was found in the trolley. It was not possible to ascertain who the tablet belonged to. The manager disposed of it immediately. Some of the medicine administration record sheets were looked at. Staff need to take care when signing the records, in particular records relating to the administration of Warfarin, as in several instances they had been signed and then crossed out and the correct dose signed. An oxygen canister was stored in the home. A sign needs to be provided so that people are aware of its location should a fire break out. There is a contract in place for the disposal of medicines. David Lewis Centre Frederick Harwood House DS0000018770.V352050.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. There is a good procedure in place, which means that people’s complaints and concerns are listened to and acted on. EVIDENCE: There is a complaints policy and procedure in place therefore staff and people living in the home know who to approach should they have concerns. A record of complaints received is kept; this identifies the action taken by the manager to ensure that peoples concerns are listened to and acted on. Safeguarding procedures are also in place. The David Lewis Centre has a protection and social work department and all allegations are reported so that the most appropriate action can be taken. All staff have had training in safeguarding adults so people living in the home should be protected from harm or abuse. David Lewis Centre Frederick Harwood House DS0000018770.V352050.R01.S.doc Version 5.2 Page 18 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 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. Improvements have been made so that people now live in more pleasant surroundings. EVIDENCE: There have been considerable improvements made to the environment since the last inspection. The number of people who can be accommodated at Frederick Harwood House has been reduced. This means that there are no longer any double rooms within the home and so the privacy and dignity of people living in the home is maintained. David Lewis Centre Frederick Harwood House DS0000018770.V352050.R01.S.doc Version 5.2 Page 19 Information received before the site visit states that the people living in the home chose the furniture and fittings. Two conservatories have been built since the last site visit. These provide a pleasant place for people using the service to use. The room for people who smoke has been altered to a smaller room with an extractor fan fitted. The remaining part of that room has been converted to an office for staff to use. One of the lounges previously used for people living in the home is now used for staff meetings etc. Information obtained before the site visit states that there are plans to redecorate and refurbish all rooms in the home. The home was clean and tidy on the day of the site visit. Cleaning services are provided daily to make sure that the home is kept clean. David Lewis Centre Frederick Harwood House DS0000018770.V352050.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. The staffing team have the qualifications and are supported thus ensuring that the needs of the service users are met. EVIDENCE: There are enough staff working in the home to meet the needs of the people living there. The following comments were made on survey forms we received before the site visit: ‘The staff make every effort to help our relative’ ‘The staff are a very caring and enthusiastic group of people’ ‘There is a significant variation in the quality of individual carers’ ‘Permanent staff provide excellent care when time permits, agency staff sometimes seem to lack the knowledge and skills required’ David Lewis Centre Frederick Harwood House DS0000018770.V352050.R01.S.doc Version 5.2 Page 21 The David Lewis Centre has its own training centre and all new staff go through an induction training programme there before they start work in the home. A new member of staff confirmed that she had gone through a thorough induction about the Centre and the home so she felt confident and knowledgeable about the policies and procedures of the Centre. Forty-six care staff work at Frederick Harwood House. Twenty of these have National Vocational Qualification (NVQ) in care at level 2 or equivalent. Eighteen staff are working towards this award and when they complete this, most of the staff working in the home will have a qualification in care. There is a good recruitment procedure for the Centre and three staff files were examined at this visit. These contained the necessary checks to ensure that staff are suitable to work in the care industry. All staff spoken with said they felt supported in their training and are provided with information on the different courses available to them. David Lewis Centre Frederick Harwood House DS0000018770.V352050.R01.S.doc Version 5.2 Page 22 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 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. The home is well managed so people using the service can be confident their needs will be met. EVIDENCE: The registered manager is a registered general nurse who has worked at the home for a considerable length of time. She also holds a NVQ Level 4 in management. There is a quality assurance system in place. Questionnaires are sent out to find out what people living in the home think about it. The questionnaires are in small writing and may not be suitable for everyone using the service. Other formats should be considered to ensure that the views of all of the people living in the home are obtained. David Lewis Centre Frederick Harwood House DS0000018770.V352050.R01.S.doc Version 5.2 Page 23 The results of the questionnaires are then collated for the manager to action. The manager said that meetings are held with the people living in the home to find out their views on the running of the home. However, minutes of these meetings were not available so it was difficult to see how people living in the home had influenced how the home was run. The manager told us that she was going to ensure that the home is made more homely and less ‘clinical’. One of these actions is to ensure that the nurses working on the unit are not called out to attend to other matters across the centre. This means that there should be less disruption for people living in the home. The David Lewis Centre employs a Health and Safety Co-Coordinator. He has the responsibility to oversee all areas associated with health and safety legislation. As identified previously there was no risk assessment done for one person who used bedside rails so staff cannot be confident that these will maintain this person’s safety. The manager said that since the last inspection all doors in the home have been fitted with closures so enhancing safety in the event of a fire. Staff spoken with confirmed that they had been done fire safety training. The fire logbook was checked. Checks on the fire alarm system had not been recorded for some time. The manager told us that these checks had been carried out but the member of staff failed to them. David Lewis Centre Frederick Harwood House DS0000018770.V352050.R01.S.doc Version 5.2 Page 24 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 3 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 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 2 X X 2 X David Lewis Centre Frederick Harwood House DS0000018770.V352050.R01.S.doc Version 5.2 Page 25 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 YA6 Regulation 15 (1) (2) Timescale for action Staff must ensure that a care 31/03/08 plan is developed when a need is identified and that the care plan is evaluated regularly and changed when a persons needs change. This is to make sure the most appropriate care is given to the person. Risk assessments must be done 28/02/08 before anyone uses bedside rails to promote the safety of the resident. Tests on the fire alarm must be 28/02/08 done and recorded weekly to ensure that the system is in good working order should a fire break out. Requirement 2 YA9 13 (2) (c) 3 YA42 23 (4) (c) (v) David Lewis Centre Frederick Harwood House DS0000018770.V352050.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA7 YA20 YA24 Good Practice Recommendations Staff should consider the different ways in which they can involve the person using the service in any decisions made about their care and any changes made to their care plans. A sign needs to be in place wherever oxygen is stored. The medicine storage room should be refurbished to minimise the risk of cross infection. David Lewis Centre Frederick Harwood House DS0000018770.V352050.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North West Regional Contact Team Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI David Lewis Centre Frederick Harwood House DS0000018770.V352050.R01.S.doc Version 5.2 Page 28 - 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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