Care Home: The Ley Community

Similar services:

• Flint House
• Yeldall Manor
• Cherwood House Care Centre

What the care home does well What has improved since the last inspection? There were no areas for improvement were identified from the standards assessed at the last inspection. This service recognises through its quality monitoring process areas for development and improvement. What the care home could do better: There are no areas for improvement identified from the standards assessed at this inspection. CARE HOME ADULTS 18-65 The Ley Community Sandy Croft Sandy Lane Yarnton Oxfordshire OX5 1PB Lead Inspector Nancy Gates Unannounced Inspection 30th April 2008 09:45 The Ley Community DS0000013104.V371666.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Ley Community DS0000013104.V371666.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Ley Community DS0000013104.V371666.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Ley Community Address Sandy Croft Sandy Lane Yarnton Oxfordshire OX5 1PB 01865 378600 01865 842238 bev.smith@ley.co.uk 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) The Ley Community Mr Paul Goodman Care Home 58 Category(ies) of Past or present alcohol dependence (58), Past or registration, with number present drug dependence (58) of places The Ley Community DS0000013104.V371666.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total number of persons that may be accommodated at any one time must not exceed 58 12th December 2006 Date of last inspection Brief Description of the Service: The Ley Community is a ‘therapeutic community’ situated within a village on the outskirts of Oxford, accommodating up to 58 people. The Community provides a structured and specialist programme for individuals to overcome drug and alcohol problems. This includes opportunities for change, re-building self-esteem and subsequently to move on to independent employment and accommodation. The accommodation comprises of three large residential units, set within large and exceptionally well-maintained grounds. An outdoor swimming pool and multi purpose sports pitch are available for recreational activities structured within the programme. Staffing is provided within guidance from the CSCI and uses peer support to manage the day to day running of each building. The current fee for this service is £421 per week. The Ley Community DS0000013104.V371666.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 3 stars. This means the people who use this service experience excellent quality outcomes. The inspection of the service was a surprise visit and was a ‘key inspection’. The inspector arrived at the service at 9.45 a.m. on a weekday. The total number of hours spent at the home was 10 hours. The time spent at the home allowed for a thorough look at how well the service is doing. The inspection took into account detailed information from an Annual Quality Assurance Assessment, completed by the registered manager and also took into account information that CSCI has received about the service following the registration of the home in October 2007. All information received by the Commission for Social Care Inspection since registration, about this service was also taken into account when producing the key inspection report. Staff and the people who live at The Ley Community were very welcoming. Discussions with four people who live in the home, four staff members, and the registered manager took place within the site visit. We looked around the home including the bedrooms of individuals at their invitation. A number of records were viewed including individuals care plans, staff recruitment records, staffing rotas and maintenance/health and safety records. We looked at how well the service was meeting the standards set by the government. The report includes judgements about the standard of the service. What the service does well: The management and staff at The Ley Community continue to offer an exceptional range of experience and knowledge to support the rehabilitation needs of residents. The programme offered to residents continues to provide a structure that assists individuals throughout the rehabilitation process. The assessment and admission process places great emphasis on the commitment needed from potential residents to start the rehab process. The The Ley Community DS0000013104.V371666.R01.S.doc Version 5.2 Page 6 admissions team ensure that the maximum amount of information is available to support an admission decision. Residents’ individual plans reflect who they are, detail progress through the programme and are of a good standard. Whilst the programme has strict boundaries, residents have a clear understanding of the restrictions of the programme and the impact on decisions and independence. Risks are measured appropriately. Privacy, choices and freedoms are significantly restricted. Discussion with residents throughout the inspections continued to provide strong evidence that this is essential and underpins some of the success of the programme. “It’s been really hard at times, I kind of knew that things would be like this, but I found it difficult to accept that people would get to know absolutely everything, but that’s what makes it successful because you can’t hide anything…if you try to hide stuff people get to know and it messes everything up…it works though because it makes you think about how those relationships might influence what you do.” Clear descriptive accounts of ‘personal development’ are included within support plans. “This programme has saved my life, and helped me help others to save their lives…I’ve gained strong and solid friendships and supports…people can rely on me and me them…honesty and respect play a big part in my relationships now – they never did before…I am happy with the person I am, I actually like me, I don’t have to pretend to be somebody or something I’m not…The future belongs to me.” Plans demonstrated clear progression and achievement. An exceptional level of support and structure remains, balanced by the direction of the rehabilitation programme and the peer support. From the evidence seen, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. A good and consistent relationship has been continued with the wider community. No complaints have been received at the home since the last inspection. No information concerning complaints, concerns or allegations has been received by the Commission since the last inspection. A clear and robust complaints process is available to residents and their representatives. Complaints are managed efficiently and within appropriate timescales. Protection of residents is assured by the availability and knowledge of the local adult protection guidance. The Ley Community DS0000013104.V371666.R01.S.doc Version 5.2 Page 7 Residents expressed positive views of the accommodation offered, “It’s one hundred times better than what I’m used to”. Clear pride through being part of cleaning and maintenance “crews” ensure that all accommodation is cleaned and maintained to a high standard. Tours of the premises with residents demonstrated their continued commitment to cleaning the environment to a high standard, clearly demonstrating the requirements of participation. ‘Inspection teams’ check quality on a daily basis. Staff are competent in supporting the needs of residents. Robust recruitment procedures ensure, as far as possible, the protection of residents. Skills are supported by comprehensive training opportunities. The management structure at The Community led by the Chief Executive, Programme Director, Assistant Programme Director allows for the community to continue to operate with transparency and integrity. Administrative support staff underpin the integrity and operation of the community to an excellent standard. Copies of the reports produced by a trustee following visits have been sent to the CSCI, although changes in legislation do not require the home to send the reports to CSCI on a regular basis. 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. The Ley Community DS0000013104.V371666.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Ley Community DS0000013104.V371666.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): 2 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Clear assessments and admission documentation allow for a robust admission process. EVIDENCE: Two full time admissions staff continue to support potential residents through the admissions process, providing clear information regarding the programme and the commitment required. Detailed information is gathered to assist management staff to make an informed judgement as to whether an individual is suitable for admission. People who live at The Ley confirmed that self-referral starts the process; selfassessments, an interview and observational assessments are undertaken before and throughout the admission process. Two people stated that they appreciated the efforts of admission staff to make regular contact whilst awaiting funding decisions, which for some people could be a long time. The contact received was reassuring and helped individuals to continue in their commitment to join the programme. Full commitment to the programme from potential residents must be established before admission. The Ley Community DS0000013104.V371666.R01.S.doc Version 5.2 Page 10 Funding confirmation in addition to admission documentation has to be in place before an admission decision can be made. Decisions for admission continue to be made within a management meeting, an opportunity for presentation of assessment information including legal, funding and detoxification issues, demonstrating clear reflective practice. The Ley Community DS0000013104.V371666.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. 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. Residents’ individual plans reflect who they are, detail progress through the programme and are of a good standard. Residents have a clear understanding of the restrictions of the programme and the impact on decisions and independence. Risks are measured appropriately EVIDENCE: Support plans detail the structure and key stages of the programme. Individuals are expected to complete the plans within the ‘key stages’, describing achievement and further areas for development linking to the report produced at 10 weeks, 6months and 9 months following admission. Beliefs, attitudes and behaviours are clearly recorded to assist the assessment of where people are in the programme. The Ley Community DS0000013104.V371666.R01.S.doc Version 5.2 Page 12 Strong themes that remain within the key stages are self-examination, explanation of feelings and behaviours, this provides a clear progress report for individuals to reflect upon who they were at the beginning of the programme to where they have got to. Common themes relating to self-worth, influential relationships, criminal history, family relationships, chaotic lifestyles and very little respect for others allow for peer relationships to continue to challenge and confront individual issues. The decision to enter The Ley Community ultimately falls to the prospective resident following a stated and contractual understanding of the restrictive nature of the programme. The ‘terms and conditions of residence’, alongside the ‘ personal contact and visits information’ leave prospective residents in no doubt about how restrictive the initial stages of the programme are. Privacy, choices and freedoms are significantly restricted. Staff monitor incoming and outgoing mail and can withhold items that may be unsuitable or detrimental to ongoing rehabilitation. Staff are also present whilst telephone calls are occurring to again ensure that content of conversations is not detrimental to the individual’s progress within the programme. Contact/visits from family members/friends/partners are also restricted within the initial stages of the programme, “Whilst this is really hard you have to give yourself time to settle in and not talk to anyone who might make you think about leaving.” We took the opportunity to speak with three people who are at different stages within the programme. Discussion with the individuals provided strong evidence that restrictions remain essential and underpin some of the success of the programme. “It’s been really hard at times, I kind of knew that things would be like this, but I found it difficult to accept that people would get to know absolutely everything, but that’s what makes it successful because you can’t hide anything…if you try to hide stuff people get to know and it messes everything up…it works though because it makes you think about how those relationships might influence what you do.” Progress through the programme to re-settlement allows for the strictness of the limitations to be lifted in an aim to start the process to independent living. Risk is determined within the remit of the programme at The Ley Community. Occupational risk assessments i.e. use of the laundry, gardening equipment, use of the kitchen, are overseen by senior residents and if needed staff members. A risk management policy remains available within the community for reference and guidance. The admissions process determines if an individual would pose a risk to themselves or others. The Ley Community DS0000013104.V371666.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The support and structure within the programme remains at an exceptional level, underpinned by the importance of clear boundaries and peer support. Restrictions are clearly understood by individuals before admission to the home. The Ley Community has a consistent and open relationship with the wider community. EVIDENCE: Clear descriptive accounts of personal development remain within support plans. Plans demonstrate clear progression and achievement. People told us, “I can’t believe what the programme has given me, a chance to think …solid friends who are honest, honesty is the hardest thing to take but The Ley Community DS0000013104.V371666.R01.S.doc Version 5.2 Page 14 you can’t hide from anything here and it makes you deal with things…it’s saved my life…I feel safe and I am happy that my family know that I am safe…I feel really privileged to be here.” A Programme Liaison Co-ordinator (PLC) remains at The Ley Community to manage and oversee education and training for individuals. People continue to be encouraged and supported throughout the programme to access skills courses through a college network. Course subjects include English and numeracy facilitated by a local college tutor, potentially leading to a recognised qualification. The rehabilitation programme requires individuals to take responsibility for planning a future beyond The Ley Community, which includes finding full time employment. People confirmed that future planning is an essential element of building a life following the programme. Voluntary employment opportunities remain available with local businesses/groups. Opportunities include becoming a member of auxiliary staff at The Ley. Application and interview for the posts are undertaken. Leisure and recreational elements remain closely linked to the structure of the programme. The community has a number of birds and animals; responsibility for the care of the animals and birds is ‘built into’ recognised stages. Information received from The Ley told us that as a result of listen to residents inter-house activities have been introduced, a further smoking cessation group has been set up and that consideration is being given to employing a yoga teacher as a direct result of a request from an individual. A swimming pool and an astro-turf pitch are available for recreation. Stage four of the programme provides the remit for individuals to access the local community. Accessing the wider community at weekends is restricted although there are no ‘locked gates’ that prevent individuals from leaving. Maintaining good relationships with the wider community remains important and is facilitated within open days and through the liaison officer. Family visits to service users remain carefully facilitated and monitored. Restrictions in relation to visitors are stated within terms and conditions/contracts. ‘Exclusive relationships’ are not permitted and this is clearly stated within the home’s brochure. The people we talked to had a clear appreciation and understanding that the programme can be influenced and disrupted significantly if a relationship develops. The Ley Community DS0000013104.V371666.R01.S.doc Version 5.2 Page 15 People who live at The Ley are responsible for catering, including ordering of supplies, menu planning and the preparation of meals. Comments regarding the standard of the food were generally positive. An expectation of the programme is for people to dine together. Three meals a day are provided, plus supper. The Ley Community DS0000013104.V371666.R01.S.doc Version 5.2 Page 16 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 are appropriately supported to meet their health care needs. Medication is stored and administered appropriately. EVIDENCE: The programme continues to require individuals to have a high level of personal responsibility for personal hygiene and the community; peer support ensures that levels are maintained. Female service users are supported within single sex groups to ensure their needs are being listened to. A female resident confirmed that issues for women are A GP can be accessed on a weekly basis within the home. All other primary health care needs can be met upon request. Dental treatment is available. Healthcare plans are written as required dependent on changing need. The Ley Community DS0000013104.V371666.R01.S.doc Version 5.2 Page 17 Medication storage and administration is overseen by a GP who visits the community. A more consistent approach to prescribing medication has been introduced with only one GP prescribing and monitoring individual needs. Medication is received in individualised boxes or bottles; a record of medication received is held. Medication administration records were generally accurate. Medication is stored appropriately. The pharmacist who supplies medication to The Ley has conducted two audits of the storage and administration of medication and will highlight improvements if needed. Staff continue to receive training on an annual basis from a local pharmacist regarding the safe storage and administration of medication. The Ley Community DS0000013104.V371666.R01.S.doc Version 5.2 Page 18 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. A clear and robust complaints process is available to the people who live at The Ley residents and their representatives. Protection of residents is assured by the availability and knowledge of the local Safeguarding Adults guidance. EVIDENCE: No complaints have been received at the home since the last inspection. We have not received any information concerning complaints, concerns, or allegations since the last inspection. Information regarding how to complain is available to all individuals who reside at The Ley. People confirmed that they are always people to talk to if needed and are aware that issues can be addressed formally through the complaints procedure. A clear and robust complaints procedure is available to both the people who live at The Ley and their representatives, however the information contains our previous contact details and should be updated to include the new contact details of CSCI. The home has a copy of the multi agency guidance for Safeguarding Adults and the registered manager has a clear understanding of the local Safeguarding The Ley Community DS0000013104.V371666.R01.S.doc Version 5.2 Page 19 Adults procedure. The Ley Community has policy documentation relating to the protection of vulnerable adults. The Ley Community DS0000013104.V371666.R01.S.doc Version 5.2 Page 20 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. A good standard of accommodation is provided for people who live at The Leys. The cleanliness of the accommodation is of an excellent standard. EVIDENCE: Accommodation provided remains at a generally good standard. An ongoing programme of re-decoration and re-furbishment has made improvements in a number of areas. People who live at The Ley expressed positive views of the accommodation offered. People remain proud of being part of cleaning and maintenance “crews” to ensure that all accommodation is cleaned and maintained to a high standard. The Ley Community DS0000013104.V371666.R01.S.doc Version 5.2 Page 21 Shared rooms remain and are considered a very important element of the programme. All rooms viewed were exceptionally clean and tidy, an element of the programme that must be adhered to. Female residents ‘share’ rooms, privacy continues to be respected. All areas within the home are exceptionally clean. Cleaning “crews” and all other household members commit to cleaning the environment to a high standard. ‘Inspection teams’ continue to check quality on a daily basis. The Ley Community is set in large and well-maintained grounds that include a large pond, bird aviaries and grazing area for the animals cared for by individuals at The Ley. Residents have been involved in creating a sensory area within the garden which includes the use of planting pathways, wicker sculptures/furniture and motion sensor sounds and music, demonstrating a commitment within the programme to enhance, develop and support individuals skills. An astro-turf pitch and an outdoor swimming pool are available within agreed leisure time. The Ley Community DS0000013104.V371666.R01.S.doc Version 5.2 Page 22 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are competent in supporting the needs of residents. Skills are supported by comprehensive training opportunities. A clear and robust recruitment process ensures the protection of residents. EVIDENCE: Staff spoken with are knowledgeable regarding the needs of people at The Ley Community, personal experiences often giving greater insight into the challenges of the programme. People who live in The Ley continue to express confidence in the skills and understanding of the staff team commenting that, “it’s good to talk with people who have been here and have got through it”. Six staff files were viewed. Clear, consistent and up to date records are held reflecting the requirements of the standards and legislation. A photograph is included within staff files. The Ley Community DS0000013104.V371666.R01.S.doc Version 5.2 Page 23 The recruitment and employment of previous residents may highlight a number of issues within recruitment checks, but acknowledgement is made of a valuable experience and support that can be provided from people who have completed the programme. Core training including fire safety, health and safety, first aid, food hygiene, risk assessment and care planning and co-ordination for people with drug and alcohol problems were stated to be undertaken on a regular basis. Staff confirmed that training relating to the needs of the people who may reside at The Ley is available. Training records must be updated to confirm training courses attend by staff. The author and founder of therapeutic communities visited The Ley and concluded that the programme is ‘sound’. The visitor made suggestions for consideration and possible change in relation to staff training. The Assistant Programme Director confirmed that the training available to staff is being reviewed in line with the recommendations and that a new training programme will made available in the near future. Specialised training and a nationally recognised qualification are offered to all staff members allowing staff to demonstrate competence to support the ongoing and changing needs of people who live in the home. The Ley Community DS0000013104.V371666.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The management structure allows for aims and objectives to be achieved by all community members whilst ensuring health and safety responsibilities are upheld. The quality of support offered to residents is monitored effectively. EVIDENCE: The management structure at The Community led by the Chief Executive, Programme Director and Assistant Programme Director continues to allow the community to operate with transparency and integrity. The Ley Community DS0000013104.V371666.R01.S.doc Version 5.2 Page 25 Changes to the management of The Ley are planned for the near future but are being planned to limit disruption to the programme and support provided to people who live at The Ley. Administrative support staff continue to underpin the integrity and operation of The Community and do so to an excellent standard. An annual report is produced at The Ley Community detailing the achievement of aims and objectives and the plans for the forthcoming year and includes the contribution of people who are living in the home. A trustee of The Ley Community visits on a monthly basis to assess the quality of support and service provided. The visits ensure that the people living at the home are given the opportunity to voice their views and can contribute to the programme and possible changes. Records viewed regarding health and safety were up to date. The author and founder of therapeutic communities visited The Ley and concluded that the programme is ‘sound’. The visitor made suggestions for consideration and possible change. Consideration is being given to the suggestions made in an effort to make improvements to the programme. The Ley Community DS0000013104.V371666.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 4 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 4 STAFFING Standard No Score 31 X 32 4 33 X 34 4 35 X 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 4 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 4 X 3 X X 3 X The Ley Community DS0000013104.V371666.R01.S.doc Version 5.2 Page 27 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Ley Community DS0000013104.V371666.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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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