Inspection on 19/08/08 for Sherringham Lodge

This is the latest available inspection report for this service, carried out on 19th August 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sherringham Lodge 14/02/06

Sherringham Lodge 21/07/05

Sherringham Lodge 14/09/04

Sherringham Lodge 27/04/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOME ADULTS 18-65 Sherringham Lodge 70 Sherringham Avenue London N17 9RP Lead Inspector Susan Shamash Unannounced Inspection 19th August 2008 01:15 Sherringham Lodge DS0000010809.V369663.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 Sherringham Lodge DS0000010809.V369663.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. Sherringham Lodge DS0000010809.V369663.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sherringham Lodge Address 70 Sherringham Avenue London N17 9RP 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) 020 8376 0860 Mrs Seela Khadun Mrs Seela Khadun Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Sherringham Lodge DS0000010809.V369663.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th February 2007 Brief Description of the Service: Sherringham Lodge is registered as a care home providing care and accommodation for up to 4 people with a learning disability. It is a single private home with the registered provider also registered as the homes manager. The home is located in a quiet residential road and is close to a range of amenities including local and High Street shops as well as an effective public transport network. The home was opened in 1998 and is a converted domestic property that comprises two storeys. Two resident bedrooms and staff facilities are on the first floor with two further resident bedrooms, one with en-suite, and communal facilities are situated on the ground floor. The home has a well-kept accessible garden at the rear. The aim of the home is to provide a homely, domestic environment for residents with learning disabilities and to encourage them to live as independently as possible. Weekly fees for the home range between £750-£1000 depending on need, correct as of August 2008. The most recent CSCI inspection report can be obtained from the home’s office or the CSCI website at www.csci.org.uk Sherringham Lodge DS0000010809.V369663.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection was undertaken on an unannounced basis and lasted approximately four and a half hours. I was assisted by the registered manager, her husband and a staff member on duty at the home and had the opportunity to meet and speak to two people living at the home. The third resident was on holiday in Spain at the time of the inspection. Feedback forms were received from one care manager, three residents and three staff members. All provided positive feedback about the support provided within the home. I was shown around the building, and examined staff and resident records, and health and safety records as well as others relating to the running of the home. Information provided in the Annual Quality Assurance Assessment for the home was also taken into account as part of this inspection. What the service does well: The registered provider and her staff continue to provide a homely environment for residents which values and supports independence and choice. Detailed care plans are in place for all residents and appropriate support is provided to meet their physical and emotional needs. A range of appropriate educational, vocational and leisure activities are available to residents, and they are supported to go on holidays of their choice. A varied and nutritious diet is available to residents with special diets catered for appropriately. The home is furnished and decorated to a high standard and residents are encouraged to be involved in the home routines. Staff are supervised and supported appropriately and the home places a strong emphasis on training, supporting staff to take appropriate qualifications. Staff act upon the advice of external health and social care professionals to provide appropriate support to residents. Sherringham Lodge DS0000010809.V369663.R01.S.doc Version 5.2 Page 6 Rigorous health and safety procedures are in place at the home to ensure the safety of residents. Feedback from the residents and their families is very positive. One noted that ‘I have been here since April and I’m happy here.’ What has improved since the last inspection? What they could do better: More accurate records should be maintained of food served to individuals living at the home, to evidence that a varied and balanced diet is provided to meet their nutritional needs. Debris should be cleared from the rear garden, at the side of the house, for the comfort of people living at the home. A more accurate staffing rota for the home is needed, to evidence that the home is appropriately staffed for the needs of residents, and which staff member is accountable for the safety of residents at any time. A satisfactory enhanced CRB disclosure, specific to working at Sherringham Lodge, must be undertaken for an identified newly recruited staff member, and any future new staff members, prior to their working unsupervised within the home, for the protection of residents from harm. A formal quality assurance audit must be undertaken at least annually, and more accurate records should be maintained of residents’ finances and property kept for safekeeping by the home, to protect people living at the home from financial abuse as far as possible. It is recommended that person centred plans for people living at the home should be made more accessible, by use of pictures, photos, audio or video Sherringham Lodge DS0000010809.V369663.R01.S.doc Version 5.2 Page 7 formats, so that they can be as involved as possible in determining these plans. The home should continue to encourage residents to go out more at weekends and in the evenings, to ensure that they have a range of recreational choices available to them. Finally it is recommended that a copy of the fire risk assessment and evacuation plan for the home, be sent for consultation with the local fire authority, to ensure that people living and working at the home are protected as far as possible in the event of a fire. 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. Sherringham Lodge DS0000010809.V369663.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 Sherringham Lodge DS0000010809.V369663.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 and 5. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective residents can be assured that their individual aspirations and needs will be properly assessed. Residents benefit from a statement of terms and conditions with the home to ensure that their rights are protected. EVIDENCE: I looked at all three residents’ files, and these contained assessments of needs undertaken by the local authority funding the placements in addition to the registered manager’s own assessments, which she undertakes personally. These assessments appeared to be holistic, including cultural, religious and lifestyle needs and choices. I had the opportunity to speak to the resident most recently admitted to the home and they confirmed that although they had been admitted due to unforeseen circumstances within their family setting, they had been consulted about the move as far as possible. Each resident had a contract with the local authority and a statement of terms and conditions with the home as appropriate. These had been updated to specify the room to be occupied in each case, as required at the previous inspection, to further protect residents’ rights. Sherringham Lodge DS0000010809.V369663.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 and 10. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from individual care plans that reflect their needs and goals. They are supported to make decisions about their lives and to take appropriate risks in developing independence skills, and their confidentiality is protected. EVIDENCE: The residents’ files seen during this inspection contained a detailed care plan, including social, cultural, religious and emotional needs. There was evidence on file that care plans had been reviewed recently in addition to monthly summaries regarding residents’ progress on goals identified in their care plans. People living at the home that I spoke with indicated that they are consulted about the care and support provided to them as appropriate. One person told me that they receive support from staff to go out on shopping trips and social activities in the local community. Staff advised that they continue to work with one particular resident to learn the values of different coins so that they had a better understanding of money. Sherringham Lodge DS0000010809.V369663.R01.S.doc Version 5.2 Page 11 Risk assessments were in place for all residents including guidelines for a resident who uses a computer on a regular basis, to avoid eye strain and repetitive strain injury. As recommended, staff had undertaken training in Person Centred Planning methodology. However this had not yet been fully incorporated into people’s care plans. It is recommended that person centred plans for people living at the home should be made more accessible, by use of pictures, photos, audio or video formats, so that they can be as involved as possible in determining these plans. As recommended the system for storing care plans had been reviewed so that staff can access them in the event of an emergency and consult and update care plans at any time. As required at the previous inspection, confidentiality procedures within the home had been reviewed so that there are no notices posted in public areas detailing residents’ individual care needs, and the home’s telephone in the lounge is not used to discuss confidential information. Secure storage arrangements for care plans and daily notes were available within the lounge, and this was used appropriately during the inspection. Sherringham Lodge DS0000010809.V369663.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, 14, 15, 16 and 17. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are encouraged and supported to develop and maintain relationships, and to enjoy appropriate activities of their choosing both within the home and in the community. They are treated respectfully and encouraged to make their own lifestyle choices and take appropriate responsibilities. The food served in the home provides residents with individual choices, and supports them to enjoy a healthy diet. EVIDENCE: One resident attends various courses at a local college and another person attends a luncheon club on a Monday, a local day centre two days a week and a farm project on a Thursday. They have structured programmes including visits to a farm project and cinema trips. The most recently admitted resident is not currently undertaking Sherringham Lodge DS0000010809.V369663.R01.S.doc Version 5.2 Page 13 structured activities away from the home, but is hoping to take up an arts course at college this autumn. The manager confirmed that she had taken this person to visit the college, and would be enrolling in September. Staff advised that they support these residents to undertake some activities within the home and local area, and this was confirmed by residents spoken to. Records seen in the home show that residents have the opportunity to enjoy a number of activities inside and outside the home. I was impressed to note that the residents continue to have at least an annual holiday individually, to different destinations, with support from staff. One resident was away in Spain visiting family members at the time of the inspection, and had been there earlier in the year. Another enjoyed a holiday in Blackpool last year. The registered manager advised that the home continues to place great importance on encouraging residents to develop and maintain friendships that they make. Residents confirmed that they are supported to maintain contacts with their family members on a regular basis, and records confirmed that one person had been supported to visit their relative regularly, when ill in hospital. Within the home, residents are supported with numeracy sessions, cooking and developing their daily living skills, in addition to dancing, reading magazines, knitting, doing puzzles, having facials and manicures, listening to the radio and watching television. Residents are encouraged to make use of facilities in the local area including a disco club attended once weekly, visits to local shops, the library and walks in the park. At the previous inspection it was recommended that more trips out of the home be offered to residents at weekends and in the evenings. There had been recent trips to Alexandra Palace, Paradise Park, Bruce Castle, a fun fair and the seaside within recent weeks. One resident told me that they had been to the cinema several times including recent trips to Mamma Mia and the X files. Care plans evidenced that staff support residents to undertake individual activities of their choice, for example one resident subscribes to the ‘New Scientist’ magazine, and another is supported to carry out arts and craft work within the home. In the Annual Quality Assurance Assessment for the home the manager noted that they had taken service users to ‘Black History Celebration Week’ at College of North East London. Residents said that they enjoyed the choice of meals served within the home. One resident is provided with a vegetarian diet. There was evidence in residents’ care plans that healthy eating is encouraged, and that the advice of specialists such as dieticians has been sought where appropriate. Sherringham Lodge DS0000010809.V369663.R01.S.doc Version 5.2 Page 14 The home was well stocked with fresh fruit and vegetables alongside a range of meat, fish, poultry and vegetarian foods. However records of food served to individuals living at the home, were not sufficiently accurate to evidence that a varied and balanced diet is provided to meet their nutritional needs. Records are completed according to the menus in advance, but they are not always updated to reflect when different options have been chosen by people living at the home. Sherringham Lodge DS0000010809.V369663.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 who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are supported appropriately with their physical and emotional health needs taking account of their preferences. They have access to appropriate medical professionals to meet their health needs, and are protected by systems in place, which govern the administration and handling of medication. EVIDENCE: People spoken to indicated that they received the appropriate emotional and physical support from staff. Observation of the relationships between staff and residents during the inspection confirmed supportive interactions. All residents are registered with a local GP and evidence of appointments were seen in the home’s diary and within each resident’s case file evidencing that they had regular dental and optician appointments as appropriate. Sherringham Lodge DS0000010809.V369663.R01.S.doc Version 5.2 Page 16 Where residents had hospital appointments to follow up health concerns, these were clearly recorded indicating action needing to be taken following each visit. Medication was appropriately stored in a lockable wall cabinet located in the staff sleeping-in room. Records demonstrated that the staff team have received training in the safe handling and administration of medication. The records of receipt, administration and disposal of medication were completed appropriately and an appropriate medication administration policy and procedure was also in place. Administration of homely remedies and dietary supplements such as cod liver oil, were being recorded on the medication administration records for clarity. The temperature in the medication cabinet was noted daily to ensure that it does not exceed 25°C for safe storage of medication at room temperature. Sherringham Lodge DS0000010809.V369663.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 who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents have the opportunity to complain, and are protected by the homes adult protection policies. EVIDENCE: The home has a complaints procedure that meets the requirements of this Standard. There have been no complaints made to the home, or to the CSCI in respect of this home since the last key inspection. Seven compliments had been recorded by residents and their relatives. It remains recommended that records be maintained of any concerns raised by residents indicating how these are addressed in each instance, rather than only recording formal complaints raised, in order to evidence that the home is receptive to residents’ concerns. The registered provider has undertaken a one-day “training the trainer” course run by the London Borough of Barnet, which focussed on adult protection procedures. All but the most recently recruited staff member had been trained in this area of practice. No issues relating to the protection of residents, had arisen since the previous key inspection. Residents spoken to during the inspection indicated that they felt able to speak to staff or the manager if they were unhappy about anything in the home, and that they felt safe living in the home. Sherringham Lodge DS0000010809.V369663.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 and 30. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a clean, homely and comfortable environment in which their safety is promoted. EVIDENCE: The home is a converted domestic property that blends in well with the immediate neighbourhood, and is conveniently located for shops and public transport. A tour of the building showed that the home was, comfortable, well decorated and maintained, and cleaned to a high standard. Appropriate laundry facilities are available and there is a shower accessible to people with restricted mobility on the ground floor. Residents spoken to indicated that they were satisfied with their private rooms and the communal areas within the home. The inspector visited all rooms and noted that each had been personalised and was furnished appropriately. Residents told the inspector that they kept their rooms clean and tidy with support and assistance from staff when needed. Sherringham Lodge DS0000010809.V369663.R01.S.doc Version 5.2 Page 19 The garden area was attractive with flowers in full bloom, however there were some debris piled at the side of the house. The manager advised that these were to be removed, and that the area under them was due to be paved in order to make the garden more accessible. Sherringham Lodge DS0000010809.V369663.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 and 36. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. More rigorous recruitment procedures are needed to protect residents in the home. The commitment shown by the home and individual staff to training and professional development ensures that residents are supported by appropriately trained, experienced and supervised staff. EVIDENCE: Although a rota was available for the home’s staffing this was not entirely accurate regarding staffing on the day of the inspection, and it did not appear to include current changes regarding staff cover for the home. A requirement is made accordingly. The home has a small staff team, which has remained largely consistent over the last few years. Inspection of three staff files indicated that Criminal Records Bureau (CRB) disclosures, two references, application forms and identity documents had been obtained for each staff member. However the enhanced CRB disclosure for the staff member most recently recruited to the home was not undertaken by the home for working at Sherringham Lodge, but was from a previous employer. A requirement is made accordingly and the home must undertake its own enhanced CRB disclosures prior to any future Sherringham Lodge DS0000010809.V369663.R01.S.doc Version 5.2 Page 21 new staff members, working unsupervised within the home, for the protection of residents from harm. In the Annual Quality Assurance Assessment for the home the manager advised that all staff are NVQ trained. One Staff member has also achieved NVQ level 3 in Care and the A1 Assessor Award and is due to commence work towards the level 4 award this year. Training courses undertaken by staff include Communication Skills for working with people who have Learning Disabilities and Challenging Behaviour, Basic First Aid, Principles of Fire Safety, Safe Handling of Medication, Infection Control, Care Planning, Makaton, Food Hygiene, Safeguarding Adults, Manual Handling and Empowering Personal Care. As required at the previous inspection staff had undertaken further fire safety and manual handling training. There were also records of each staff member’s induction programme, regular supervision sessions and training and development certificates. The manager advised that having completed annual appraisals for staff, they had identified further training courses for staff members to undertake including Person Centred Care, Mental Capacity Act, Food Hygiene (Refresher), Safe Manual Handling for Managers and Medication Training (Advanced). Discussion with one staff member working in the home indicated that she was appropriately experienced and knowledgeable about the needs of residents within the home, and was receiving sufficient management suport. Sherringham Lodge DS0000010809.V369663.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, 41 and 42. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is generally well managed, but there is room for improvement in quality assurance procedures and procedures in place to safeguard people’s finances. Rigorous health and safety systems are in place to ensure the promotion of residents welfare. EVIDENCE: The home’s manager has owned and managed the home since it opened in 1998. She is appropriately qualified and knowledgeable about the needs of the residents at the home. She continues to undertake relevant training for her role. Sherringham Lodge DS0000010809.V369663.R01.S.doc Version 5.2 Page 23 Observation of the running of the home and inspection of records indicated that the home is well run and that the residents’ wellbeing is central to all policies at the home. As recommended arrangements had been made for staff to access care plans in the absence of the manager, with secure storage made available in the lounge area. Records indicated that regular staff meetings are held, but residents meetings are not held on a regular basis. The manager advised that residents do not tend to relate well to each other in such meetings and therefore one to one key worker meetings are held with each resident instead on a monthly basis. Records of these meetings were available within people’s files as appropriate. The manager had completed the Annual Quality Assurance Assessment for the home as appropriate, and is aware that a more formal quality assurance system must be put in place, with the results of each audit sent to the local CSCI area office at least annually. Resident monies looked after by the home were inspected, and these generally corresponded with the records of transactions maintained for each resident and their bank account records as appropriate. Residents confirmed that they were able to access their monies whenever needed. However records were not sufficiently rigorous so that the amount taken out by a resident at any time could be determined – this often being recorded only after the change was returned. The correct amount of change was not available in one person’s monies maintained for safekeeping by the home. Where there if insufficient change to balance residents monies correctly, this must be clearly recorded, to avoid any errors. No residents were signing for monies taken out, even though some were able to understand such transactions and sign accordingly. A requirement is made accordingly. Other property kept for safekeeping such as bank or cheque books, or passports, should also be signed in and out of the home, to protect people living at the home from financial abuse as far as possible. Records of incidents and accidents were available as appropriate and safe practices are in place within the home including a range of current health and safety certificates and appropriate safety measures in place. Current gas, electrical wiring and portable appliances safety certificates were available for the home as appropriate. Systems are also in place to ensure that fire equipment is regularly tested and serviced, and fire drills are undertaken. Fire drill records included the staff and residents involved in each fire drill and the time of each drill as appropriate, including an evening fire drill. Sherringham Lodge DS0000010809.V369663.R01.S.doc Version 5.2 Page 24 It is recommended that a copy of the fire risk assessment and evacuation plan for the home, should be sent for consultation with the local fire authority, to ensure that people living and working at the home are protected as far as possible in the event of a fire. Sherringham Lodge DS0000010809.V369663.R01.S.doc Version 5.2 Page 25 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 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 2 X 2 3 X Sherringham Lodge DS0000010809.V369663.R01.S.doc Version 5.2 Page 26 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 YA17 Regulation 16(2i) 17(2) Sched 4 (13) Requirement The registered person must ensure that more accurate records are maintained of food served to individuals living at the home, to evidence that a varied and balanced diet is provided to meet their nutritional needs. The registered person must ensure that debris are cleared from the rear garden, at the side of the house, for the comfort of people living at the home. The registered person must ensure that a more accurate staffing rota for the home is maintained, to evidence that the home is appropriately staffed for the needs of residents, and which staff member is accountable for the safety of residents at any time. The registered person must ensure that a satisfactory enhanced CRB disclosure, specific to working at Sherringham Lodge, is undertaken for the identified newly recruited staff member, and any future new staff members, prior to their working DS0000010809.V369663.R01.S.doc Timescale for action 03/10/08 2. YA24 23(2o) 05/12/08 3. YA32 17(2) Sched 4 (7) 26/09/08 4. YA34 19 Sched 2 (7) 19/08/08 Sherringham Lodge Version 5.2 Page 27 5. YA39 24 6. YA41 17(2) Sched 4 (9) unsupervised within the home, for the protection of residents from harm. The registered person must ensure that a formal quality assurance audit is undertaken at least annually, and that the results are incorporated into the business plan for the home and also sent to the London Regional CSCI office. The registered person must ensure that more accurate records are maintained of residents’ finances kept for safekeeping by the home. Residents that are able to, should sign for all transactions, a clear record must be maintained of all monies taken out, and the change that is returned on each occasion. Other property kept for safekeeping such as bank or cheque books, or passports, should also be signed in and out of the home, to protect people living at the home from financial abuse as far as possible. 07/11/08 26/09/08 Sherringham Lodge DS0000010809.V369663.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations It is recommended that person centred plans for people living at the home should be made more accessible, by use of pictures, photos, audio or video formats, so that they can be as involved as possible in determining these plans. It is recommended that the home continue to encourage residents to go out more at weekends and in the evenings, to ensure that they have a range of recreational choices available to them. It is recommended that a copy of the fire risk assessment and evacuation plan for the home, should be sent for consultation with the local fire authority, to ensure that people living and working at the home are protected as far as possible in the event of a fire. 2. YA12 3. YA42 Sherringham Lodge DS0000010809.V369663.R01.S.doc Version 5.2 Page 29 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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