Inspection on 26/09/08 for Lawrie Park Lodge

This is the latest available inspection report for this service, carried out on 26th September 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lawrie Park Lodge 21/02/07

Lawrie Park Lodge 20/06/06

Lawrie Park Lodge 09/01/06

Lawrie Park Lodge 17/08/05

Lawrie Park Lodge 22/11/04

Lawrie Park Lodge 25/06/04

Extracts from inspection reports are licensed from CQC, this page was updated on 17/12/2008.

CARE HOME ADULTS 18-65 Lawrie Park Lodge 27 Lawrie Park Road Sydenham London SE26 6DP Lead Inspector Rosemary Blenkinsopp Key Unannounced Inspection 26th September 2008 09:45 Lawrie Park Lodge DS0000025630.V365063.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 Lawrie Park Lodge DS0000025630.V365063.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. Lawrie Park Lodge DS0000025630.V365063.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lawrie Park Lodge Address 27 Lawrie Park Road Sydenham London SE26 6DP 0208 778 5388 0208 778 5404 nand@seeboruth.fsnet.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) Mr Nundoo Nand Seeboruth Mr Nundoo Nand Seeboruth Care Home 19 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (19) of places Lawrie Park Lodge DS0000025630.V365063.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 19 26th October 2007 Date of last inspection Brief Description of the Service: Lawrie Park Lodge is a large detached house located in a quiet residential road in Sydenham. A bus service passes the door and two railway stations are within walking distance as well as local shops, pubs and community facilities. The home is registered for 19 adults of either gender between 18 and 65 who have experienced mental health related issues. Accommodation is provided over three floors of the house. Communal space is provided on the ground and lower ground floor. The proprietors have extended the communal space with the provision of a large conservatory attached to the dining room on the lower ground floor. A newly fitted rehabilitation kitchen has been recently completed. The home has an in house activity programme in addition to supporting people to access activities outside of the home. Weekly fees range between £700.00 and £ 900.00 for care accommodation and food. Extras are payable for newspapers, cable TV, chiropody and hairdressing. Lawrie Park Lodge DS0000025630.V365063.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating of the service is 2 stars. This means the people who use this service experience good. The inspection was conducted over a one day period. The manager facilitated the site visit with the assistance of the operations manager. Prior to the inspection the manager had completed the AQAA and forwarded this to the CSCI. Seven comment cards were provided and returned during the inspection including five from residents. During the visit the inspector met with several residents. On two occasions, seven members of the multi disciplinary team were contacted however only two persons could be contacted to provide feedback. The two members of the multidisciplinary team gave information on the home, which indicated good outcomes for residents in a professional, well organised service. Staff were interviewed as part of the site visit. All of the information obtained from the sources identified above has been incorporated into this report. A selection of documents were inspected including care plans, staff personnel files as well as health and safety records. Feedback was provided to the manager at the end of the inspection. Other information which has been considered when producing this report and rating, is the information supplied and obtained throughout the year including Regulation 37 reports and complaints. What the service does well: The home has retained a fairly stable staff team which for mental health residents is essential as change often prompts deterioration in behaviour Staff in the home were knowledgeable about their key residents and the care and support they needed. Information received from members of the visiting multi disciplinary team – was positive in respect of service and the outcomes for residents. Staff were said to be knowledgeable about resident’s needs and provided the support they needed. Lawrie Park Lodge DS0000025630.V365063.R01.S.doc Version 5.2 Page 6 Those staff interviewed demonstrated a good knowledge of working in a residential setting and the resident’s needs. The environment is well maintained which is difficult with this type of client. Records and documentation were well organised available and accessible. What has improved since the last inspection? What they could do better: More details are required in care plans and risk assessment to ensure that staff have sufficient information on which to provide consistent care. This is particularly true when dealing with mental health issues. Medications, which are hand transcribed, need to have two signatures to confirm the accuracy of the information recorded. All complaint records need to be comprehensive in content and detail whether the complainant is satisfied with the outcome. All environmental issues, which may pose a risk to residents, need to be addressed with a risk assessment and actions to make them a safe as possible whilst remembering that it is the resident’s home. All staff working in the home need to have evidence of their suitability and recruitment procedures retained including those from agencies. Please contact the provider for advice of actions taken in response to this Lawrie Park Lodge DS0000025630.V365063.R01.S.doc Version 5.2 Page 7 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. Lawrie Park Lodge DS0000025630.V365063.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 Lawrie Park Lodge DS0000025630.V365063.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. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service The pre-admissions procedures provide residents with a range of information, including visits to the service, to assist their decision making process, and enable them to establish whether the service is right for them. Staff are provided with information on which they can base an initial care plan and address resident’s needs . EVIDENCE: At the time of the inspection there were seventeen residents on site and two vacancies. All residents in this service are under Care Programme Approach, which is a system of after care and includes multi disciplinary team member input. All residents under this have a care coordinator who arranges regular reviews of the resident. All residents are requested to complete an application form for admission. The application form provides information about the home and services. Residents are issued with terms and conditions, which states the room to be occupied. The weekly fee is agreed with the funding authority, there are no self-paying residents in this service. A welcome letter is sent to the resident Lawrie Park Lodge DS0000025630.V365063.R01.S.doc Version 5.2 Page 10 once the admission is agreed. All residents are subject to a six-week trial period, which allows them time to see if the service is right for them. The documentation of two resident’s assessments were looked at. They varied in the amount of information they contained. The home’s own assessment was limited and in a tick list format although comprehensive assessment information was received under Care Programme Approach procedures in both cases. Where possible residents visit the home to sample the service, and visits by family members are also encouraged. It may not be possible for residents to have a full choice in where they are placed due to limitations on service provision. Staff confirmed that they were kept abreast of issues and this included information on perspective residents. Information was made available and they were encouraged to read it. Five resident’s comment cards indicated that they had been asked if they wanted to move into the home. The Statement of Purpose had been amended and included the range of fees payable. Lawrie Park Lodge DS0000025630.V365063.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): 6,7and 9. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service The information in care plans enables the staff to plan and deliver the care. However, care plans were limited in some of the interventions which detail how staff deliver care; hence staff would not have the information to address those issues. Without comprehensive information inconsistencies in care and approach can occur, which may negatively impact on resident’s health. Risk assessments were in place to address all activities of daily living. EVIDENCE: Two care plans were selected that of the last admission and that of a resident who had required hospital admission following deterioration in their mental health. Care plans outlined the resident’s identified physical, social and mental health care needs and the support they required. One care plan had the Lawrie Park Lodge DS0000025630.V365063.R01.S.doc Version 5.2 Page 12 signature of the staff member although was without that of the resident. The second had the two signatures. Where possible evidence of resident’s involvement in drawing up the care plan should be by way of their signature. The care plans did reflect that staff applied information contained in the CPA care plan to ensure a consistent approach. Risk assessments were in place for personal issues although again more detail was required to reduce or eliminate the risks. Six month reviews are conducted on risk assessments and care plans are amended as agreed in the CPA meetings. Some of the interventions to address the care plan issues were limited in content and required more information for staff to provide the support resident’s needed. It is essential detail is provided in care plans to ensure staff provide consistent care. Handover between the two shifts was observed. Good information was related on each resident demonstrating that staff had a good knowledge of the resident and their needs. In the staff comment cards returned it was stated that “ up to date care plans, handover on every shift, daily notes updated and the information accessible when required “. Another comment card completed by staff stated “whenever there is any new development s in their heath well being and behaviour we are given information “. Please see requirement 1. Lawrie Park Lodge DS0000025630.V365063.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 and 17. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Residents are well supported with all activities of daily living to maximise personal development and enhance rehabilitation for more independent living. Open visiting promotes and encourages residents to maintain social networks. EVIDENCE: Several residents met with us during the site visit. They related positive comments regarding their stay at the home, staff input and general support provided. They had been in the home varying amounts of time from a few months to six and half years. One resident was moving to less supported accommodation within a few days and felt that it was because of the staff support and guidance that this had been achieved. They were aware of their Lawrie Park Lodge DS0000025630.V365063.R01.S.doc Version 5.2 Page 14 key worker and her role in assisting them with rehabilitation activities. They said about the staff “they are reasonable, understanding, and nice to get on with “. Daily activities include group and individual sessions and include those, which are part of individual rehabilitation as well as social events. Individual rehabilitation programmes are in pace as each resident has different needs. Exercise equipment is available in the dining room. A new rehabilitation kitchen has been installed whereby residents can, with staff assistance prepare and cook meals to develop these skills. The environmental health gave the home a four star rating July 07, and we were advised that a further visit from them had resulted in a five star rating. There was good quality food available and in sufficient quantities. This is important as some medications increase appetite and residents need more food. Resident’s food preferences are recorded on admission. Supporting information from the UK diabetic society was in the file of a resident known to be diabetic as an aid to staff. One resident commented, “They do good chips here”. Within those comment cards returned positive responses to the questions were indicated confirming that residents had choice , freedom and a lot of input into the decision making process. Visiting is open and encouraged at any reasonable time. Residents are free to visit their families at home and weekend leave can be arranged where it is appropriate. Lawrie Park Lodge DS0000025630.V365063.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 and 20. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Health care is provided through the local community which promotes resident’s rehabilitation and engagement with services. Medications are safely managed by staff that are trained and proficient to do so. EVIDENCE: Residents in this service are encouraged and supported to attend health care in the local community. This enables them to be part of the local community whilst promoting rehabilitation and life skills. Within care plans there was records relating to visit made by members of the multidisciplinary team including visits by the district nurse. A short summary of the actual visit was recorded and any treatment required. CPA appointments and follow up meetings are held regularly to ensure that the care plan and risk assessments are current. Lawrie Park Lodge DS0000025630.V365063.R01.S.doc Version 5.2 Page 16 Medications were inspected with the assistance of the operations manager. Medications were safely stored and all found to be stored in a tidy, organised manner. Other records, which were retained, included weight charts. On the medication administration records (MAR) there were clear photographs of the individual resident and on some charts their allergies recorded. There were omissions in several charts seen in respect of medication allergies, although when checking the previous month’s charts, these were fully completed with allergies documented. The manager stated that this was due to omissions by the supplying pharmacist. This needs to be addressed and checked to ensure that the information appears on the chart. In the interim period this should be recorded by hand on the chart. Those medications received into the home were recorded. A list of staff able to administer medications was available as were records of fridge temperatures. Self-medication procedures are in place for residents, who undergo a risk assessment in relation to their competency and compliance with the self medication procedures. Medications, which are hand transcribed, need to have two signatures to confirm the accuracy of the information recorded. Medications are audited internally. Staff training is provided by the supplying pharmacist who was said to provide a good service. Two visiting professionals to the service provide good feedback. They felt that residents were well supported in their daily lives by staff who were knowledgeable about their needs. They felt that they we kept informed about residents and overall a good service was provided. Please see requirement 2. Lawrie Park Lodge DS0000025630.V365063.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 and 23. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Information on how to make a complaint was made available to staff, residents and visitors, and residents were aware of who to talk to in such instances. Staff had a working knowledge of adult protection procedures and those relating to whistle blowing which affords protection to residents. Comprehensive records need to be retained to ensure an open and transparent system for complaints is in operation. EVIDENCE: The home operates an open ethos where residents can approach staff or the management at any time with concerns. It was evident during the visit the residents felt able to raise issues with staff. Residents spoken to said that they had no concerns and were generally happy with the home. Available in the office were policies and procedures in relation to adult protection and whistle blowing, as well as information on Lewisham Social Services departments. Information on how to make a complaint was available in several documents and on display. The complaints file was in the office. This is where all concerns and complaints are recorded. In the main the records of complaints, were in respect of Lawrie Park Lodge DS0000025630.V365063.R01.S.doc Version 5.2 Page 18 residents complaining about one another, i.e. residents playing loud music. In this file there were records relating to an incident April 08 and a report by the home manager to the investigating officer. Some complaint’s information was limited in respect of what was recorded, specifically the outcome of the complaint, if the complainant was satisfied and what further action, if any, the home will take to prevent a reoccurrence of the complaint. The staff on duty were asked about adult protection issues and given scenarios including witnessing senior staff shouting at residents, the responses indicated that staff had a good grasp of adult protection matters and the need to report such. Within residents comment cards it was clear that there were several avenues where residents could raise complaints those specifically stated included key workers manager, social worker and relatives. Please see recommendation1. Lawrie Park Lodge DS0000025630.V365063.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The environment is maintained to a good standard, clean and hazard free. Residents have sufficient space in their bedrooms to personalise them to their own specifications. Comfortable communal areas provide space for socialising and relaxation EVIDENCE: The home is maintained to a good standard, which is to be commended given the resident population. Only a couple of bedrooms were inspected, as the residents were not available to give access to them. Residents have their own bedroom door keys and are encouraged to lock them when out of the home or in communal areas. The bedrooms seen were to a good standard. Bedrooms are located over three floors and are of different shapes and sizes. Lawrie Park Lodge DS0000025630.V365063.R01.S.doc Version 5.2 Page 20 There was a general lack of radiator covers; this was pointed out to the staff member who said that there was little risk posed by the surface temperatures however risk assessments should be conducted for these. In the event that a resident falls against a radiator an injury may occur, this is particularly problematic when mobility issues are apparent, or a resident suffers epilepsy. There is lift access to all floors. All areas were clean tidy and odour free. Communal areas were furnished with comfortable sofa’s a TV and maintained in a domestic fashion. There is a separate dining area as well s a conservatory for those who smoke. There is a large garden to the rear of the building and parking to the front. The home has selection of baths and showers, and each bedroom has a toilet and a sink. The handyman was in working on a shower cubicle during the inspection. It was evident ongoing maintenance and upgrading took place as the home was well cared for. There is a washing machine on each floor where residents are assisted to do their laundry. There is a domestic employed for five hours a day. She spoke to us and said she had been in post for five years and had completed her NVQ in housekeeping. She enjoyed her work and the residents who lived in the home were supportive of her efforts. Please see recommendation 2. Lawrie Park Lodge DS0000025630.V365063.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Staff are subject to robust recruitment procedures which affords protection to residents. Staff are provided in sufficient numbers to met resident’s needs. Staff receive training on the mandatory topics as well as those which are related to the current resident population, this ensures that staff are competent and capable to care for residents. EVIDENCE: The staff team in the home has male and female workers including several from ethnic minorities. This is reflective of the resident population and the home endeavours to allocate key workers to residents with whom they feel they will be able to work with. Lawrie Park Lodge DS0000025630.V365063.R01.S.doc Version 5.2 Page 22 There are three agency staff that work regularly in the home to cover vacancies occurring through holiday or sickness, the manager stated that there were no full time staff vacancies currently. One of those agency staff members had only a standard CRB supplied through the agency. She was not working on her own but under supervision. The manager stated that he had raised this with the agency. All staff must be subject to enhanced CRB clearance and POVA first checks even those supplied through an agency For those staff who work with POVA first, supervision systems must be in place whilst the enhanced CRB is obtained. The manager must be satisfied that all recruitment checks have been made and that the staff member is suitable to work in the home and evidence to verify this retained. He said that the recruitment of staff is left with the agency and does not request evidence of recruitment and training, their performance would be monitored during their working day .It is the manager’s responsibility to ensure staff are safe to work in the home. The agency staff are recruited locally using a single agency and a good working relationship has been established between them and the home. They can usually provide the home with all it’s staffing requirements. Staff personnel files were inspected, including a newly appointed support worker, to confirm robust recruitment checks are undertaken on staff employed in the home. Personnel files were securely stored in the manager’s office. Application forms references, Criminal Records Bureau (CRB) checks, and those for identity confirmation were all evidenced. The second personnel file had all recruitment checks evidenced as well as a number of training certificates retained. Certificates included those covering manual handling, mental health, fire safety and adult protection. In addition to undertaking training, staff are asked to complete a questionnaire, which assesses the individual’s knowledge on the subject for which the have received training. This gives a good measure of the value of that training and the individual’s competence in the subject. The induction form was that produced using the “Skills for Care “. In one some parts of this were incomplete, including basic topics such infection control, staff patient relationships etc. These need to be addressed to ensure that the staff are aware of the action to take in their daily work. Records of supervision were on file and staff confirmed that these were undertaken regularly, where open discussion could take place and a copy of notes taken were provided. All staff on duty were interviewed including the domestic. They were asked questions pertinent to their role. Support workers were asked about mental Lawrie Park Lodge DS0000025630.V365063.R01.S.doc Version 5.2 Page 23 health topics and had a working knowledge of such. The domestic was knowledgeable about infection control and the measures needed for COSHH. The support staff had a good grasp of their residents knowing not only their presenting problems but also social and family networks. A training matrix should be developed to ensure that all staff receive updates in the mandatory topics at the specified intervals. The training provider does automatically arrange updates when they are due, however a record in the individual staff members file is recommended. A training needs assessment of each staff member is undertaken with relevant training provided to address gaps in knowledge. All except two of the thirteen employees have achieved an NVQ qualification. Please see requirement 3. Lawrie Park Lodge DS0000025630.V365063.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): 37,39and 42. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home is managed by an experienced individual supported by the staff team. Health and safety measures provide residents with a safe home for them to live in. Quality assurance measures include the views of resident’s although relative’s staff and other parties involved in the home should be included to further develop a better service. EVIDENCE: Lawrie Park Lodge DS0000025630.V365063.R01.S.doc Version 5.2 Page 25 The owner is also the manager of this facility. He is a qualified mental health nurse. He has previous experience of this type of setting and many years working with the mentally ill. He has worked as the manager since taking it over approximately nine years ago. He is supported by the operations manager who has been in post for one year. She is fulltime has completed the RMA as well as the D32/33. She has previous experience in mental health settings. The records generally were well organised with information easy to access. The administrator had good systems in place to ensure records were well maintained. Records in relation to fire procedures included the fire risk assessment and the emergency plan. Evacuation procedures and the fire action were available. Records confirming weekly fire alarm testing and monthly emergency lighting checks were on site. During the weekly fire alarm testing all staff and residents evacuate the building. This confirms that all precautions for the prevention of fire are undertaken to maintain the building as safe as possible. The gas certificate was dated July 08. The legionella testing had been conducted September 08. Portable appliance testing electrical items had been conducted April 08, and the five year fixed wiring was addressed February 06. The lift is on a service contract which means if it breaks down a 24 hour call out system is in place. There is no lifting equipment or hoists in this home. Twelve staff attended health and safety training April 08. In a staff survey supervision was said to take place regularly. The employer’s liability insurance was on display and current. Resident’s money was securely stored. The transactions were confirmed by way of the resident’s signature. Receipts for purchases are retained only if residents provide them. Minutes of the weekly community meetings are retained. Regular audits are conducted on medications and residents finances. An annual satisfaction survey is conducted. The manager undertook in January 2008 a survey seeking the views residents and relatives regarding the service, 30 questionnaires were sent out with 21 returned. The areas included in the survey related to the accommodation meals and activities. Feedback Lawrie Park Lodge DS0000025630.V365063.R01.S.doc Version 5.2 Page 26 was provided to the residents on the findings. It is recommended that the survey results be published in a form suitable for residents to extract information from. In future surveys, it is recommended that where possible relatives and visiting professionals are encouraged to participate in the review. Lawrie Park Lodge DS0000025630.V365063.R01.S.doc Version 5.2 Page 27 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 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 4 STAFFING Standard No Score 31 X 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 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Lawrie Park Lodge DS0000025630.V365063.R01.S.doc Version 5.2 Page 28 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 YA6 Standard Regulation 15 Requirement Timescale for action 2 YA20 13 3 YA34 18 Care plans must fully detail all 30/11/08 interventions that staff are to provide to ensure they address the people who use the service’s identified care needs. All information relating to 30/11/08 medications must be recorded on the charts including allergies to protect the people who use the service. All employees must have 30/11/08 evidence of recruitment procedures retained to ensure that they are safe to work in the home. Lawrie Park Lodge DS0000025630.V365063.R01.S.doc Version 5.2 Page 29 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 YA22 2 YA24 Refer to Standard Good Practice Recommendations All information on complaints must be retained to evidence an open ethos. Risk assessments should be conducted for areas in the home which may pose a risk. Lawrie Park Lodge DS0000025630.V365063.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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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