Inspection on 01/04/08 for 1 Lawrence Road

This inspection was carried out on 1st April 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

1 Lawrence Road 07/11/07

1 Lawrence Road 15/05/07

1 Lawrence Road 29/01/07

1 Lawrence Road 11/01/06

1 Lawrence Road 29/03/05

1 Lawrence Road 28/09/04

1 Lawrence Road 09/03/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 1 Lawrence Road 1 Lawrence Road Basildon Essex SS13 2NB Lead Inspector Ann Davey Unannounced Key Inspection 1st April 2008 10:00 1 Lawrence Road DS0000018055.V360186.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 1 Lawrence Road DS0000018055.V360186.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. 1 Lawrence Road DS0000018055.V360186.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 1 Lawrence Road Address 1 Lawrence Road Basildon Essex SS13 2NB 01268 590678 01268 590678 june.lai-chun@estuary.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) Estuary Housing Association Limited Manager post vacant Care Home 2 Category(ies) of Learning disability (2) registration, with number of places 1 Lawrence Road DS0000018055.V360186.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th November 2007 Brief Description of the Service: 1 Lawrence Road provides residential care for two adults with a learning disability. The fee for the home is £2849.23 per week. Any additional fees that may occur for such items as toiletries, should be discussed directly with the registered provider. The home is a purpose built bungalow situated in a semi-rural area between Southend and Pitsea, on the outskirts of Basildon. Due to the location of the home, transport links to the area are not very good. The home consists of a lounge/dining room area, two bedrooms, a toilet/bathroom for residents, a toilet for staff and visitors, a kitchen, utility room and office. The home has a large garden/patio area to the rear of the property. There is limited parking to the front of the property. The home’s Statement of Purpose and Service User’s Guide are available from the home on request. 1 Lawrence Road DS0000018055.V360186.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 this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was a key unannounced site visit that started at 10am and finished at 3.30pm. The last key inspection took place on 7th November 2007. Following that inspection, the registered provider was asked to send us (CSCI) details of how the shortfalls identified were going to be addressed and within a time frame. This document was sent to us and was used as part of this inspection. The home had completed and returned their Annual Quality Assurance Assessment (AQAA) to us prior to the inspection. This document gives homes the opportunity of recording what they do well, what they could do better, what has improved in the previous twelve months as well as their future plans for improving the service. The information and detail provided within the AQAA has been included in this report. The manager and staff were spoken with during the inspection. Two service managers (representatives of the registered provider/person who have area management responsibility for the home) were at the home and were spoken with. One service manager was available for the morning and the other manager was available for the afternoon period. We (CSCI) received two completed surveys from clients. These were completed with the assistance of staff. We received four completed surveys from staff. Reference to feedback from these surveys has been made within this report. The day was pleasant and staff were very co-operative and helpful. The whole inspection process was undertaken with ease. The manager was in a meeting for part of the morning so a senior member of staff assessed us during that time. This was good because it gave us an opportunity to spend more time with staff. The home has not had a registered manager for over two years. The current person in charge of the day-to-day management has been in post for one year. A tour of the home took place. Throughout the inspection, care practices were observed and a random selection of records viewed. A notice advising any visitors to the home that an inspection is taking place is normally displayed. On this occasion, this was thought not necessary as no visitors were expected. All matters relating to the outcome of the inspection were discussed with the service manager and the manager of the home. They took notes so that development work could be started where necessary. Full opportunity was given for discussion and/or clarification where necessary. 1 Lawrence Road DS0000018055.V360186.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The registered provider is not undertaking regulatory monthly visits (Regulation 26 visits) to the home as required by regulation. This is the third inspection where this shortfall has been identified. This finding does not 1 Lawrence Road DS0000018055.V360186.R01.S.doc Version 5.2 Page 7 support the information provided within the home’s Improvement Plan and in the AQAA. It is important the manager follows through the issue concerning the number of staff able to drive the mini bus. The current proposal of exchanging the existing mini bus for a vehicle with an automatic gearbox enabling more staff to drive should be pursued. This would further enhance the opportunities for residents to go out and about and be more independent of each other. The manager has begun to collate information in preparation for the annual quality assurance report. This should be brought to a conclusion before the next inspection as if has been outstanding since the last visit. It is important that the registered provider assists the manager in this because it is a joint responsibility. The manager has made good progress since the last inspection and it is important that an application for the position of registered manager of the home is made. This would stabilise the management of the home even further. 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. 1 Lawrence Road DS0000018055.V360186.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 1 Lawrence Road DS0000018055.V360186.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 good. This judgement has been made using available evidence including a visit to this service. Residents can expect to receive a comprehensive pre admission assessment to ensure that their needs are met. EVIDENCE: Both residents have lived in the home since it opened. There are no plans to change the current living arrangements. No admissions have taken place since the last inspection. The home has a current admissions policy. At the previous three inspections, it was noted that an independent person acting on behalf of the individual resident’s interests had not signed their ‘terms and conditions’ document. Residents have very limited communication skills and would not be able to understand or endorse these documents. Since the last inspection, an advocate has visited the home and the manager is to contact them again requesting that they view the terms and conditions to ensure the best interest(s) of each resident is upheld. The home has a Statement of Purpose and a Service User’s Guide which is in text/pictorial style. 1 Lawrence Road DS0000018055.V360186.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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to have a plan of care drawn up by the home that broadly reflects their assessed needs. EVIDENCE: Care pans were current and orderly. From activity observed during the day and from discussion with staff, information on the documents provided a good rounded ‘pen picture’ of residents needs. The funding authority has now carried out a full review of the residents’ care. This was the first review undertaken by them for a number of years. Residents have very limited skills and abilities and therefore the content of care plans is mainly based on the home’s understanding and perception of needs and from various health agency’s input. Since the last inspection, the manager has implemented a ‘resident response’ log. This enables staff to record individual residents ‘responses’ to various activities and tasks. These ‘responses’ help staff to monitor whether an activity is pleasing to the resident 1 Lawrence Road DS0000018055.V360186.R01.S.doc Version 5.2 Page 11 or not. It is also a way of assisting staff when needing to know about individual residents preferences and wishes. The manager should be commended on this good practice. Care plan documentation has pictorial aspects to them which helps with communication. Risk assessments seen were detailed and current. Residents were unable to comment on their care. Information within their surveys that had been completed by staff, was positive. They felt that staff treated them well and were able to make themselves understood by nonverbal communication techniques. Time was spent in residents’ company during most of the morning and for part of the afternoon, suggested that they were happy and comfortable. Their interaction was limited with us, but we managed to communicate in a limited way and responses were positive. Residents’ demeanour was relaxed and in keeping with their documented needs. There was a lot of good humour and laughter in the home. From observation during the day, residents were able to make their wishes and preferences made known to staff on duty. A mixture of permanent staff and agency staff were on duty during the day. We spoke with all staff who demonstrated to us a good understanding of residents needs. From observation, residents related well to all staff at all times. 1 Lawrence Road DS0000018055.V360186.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to receive a balanced and varied diet and a developing leisure activity programme to meet their individual needs. EVIDENCE: At the previous three inspections, the corporate and individual leisure/activity programme has been reported as being very limited. This was mainly because the residents had very different leisure needs and having only two staff on duty and at any one time, external and community activities were limiting. This was further compounded by the number of shifts with only agency staff on duty that meant restricted use of the mini bus that is necessary to transport residents. Since the last inspection, the manager has made application to the owner of the home for the current mini bus to be exchanged for an automatic gearbox 1 Lawrence Road DS0000018055.V360186.R01.S.doc Version 5.2 Page 13 model. This will enable the home to have two extra drivers. This means that residents will be able to go out with staff on an individual basis more. In addition, the manager continues to work supernumery hours, so this means that there is always an ‘extra’ person in the home to help with staffing numbers at any one time. On the morning of the inspection, both residents were occupied with a meaningful and interesting activity. In the afternoon, both residents were out at different venues supported by staff. The manager understands that this area of care still needs to be developed and this was reflected within the AQAA and within the completed surveys from staff and residents. Since the last inspection, the manager has clearly made some positive improvements. On the basis of potential and work already completed and currently being explored by the manager, the outcome for this group of standards has been assessed as ‘good’. Progress will be reviewed again at the next inspection. There is a basic four weekly menus cycle. Residents can make their choice of which meal they would like to have by using a pictorial style menus placemat. A record of what each resident had eaten on a daily basis was available. Lunch served on the day looked appetising and residents were clearly enjoying the food. Records show that residents enjoy having meals out from time to time. 1 Lawrence Road DS0000018055.V360186.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to receive good health and personal care. EVIDENCE: Care plans demonstrate that residents’ personal and health care needs are assessed and recorded. Records show that residents are encouraged to make choices about what they want to wear, their daily routines and choice of food according to individual ability. During the day, we observed staff asking residents about various preferences. For example, what activity they wished to be involved in and talking with them about the afternoons programme Community healthcare input is recorded well. Residents have complex personal and health care needs. Staff said that residents are well supported by all outside agencies. One member of staff spoke positively about the GP who proves medical care for the residents who was ‘understanding’ and ‘so helpful’. Since the last inspection the manager has carried out a full review of medication practices in the home. Documentation and records seen were in good order. Training has been provided to staff for a PRN (as/when required) 1 Lawrence Road DS0000018055.V360186.R01.S.doc Version 5.2 Page 15 invasive medication administration technique that is required by one resident. The GP and clinical consultant have now signed a protocol. It is good practice for this document to be endorsed by an independent advocate as well. The manager is now waiting for the trainer to provide the home with certificates to say that staff are competent to carry out the procedure and provide details of how safe practice will be monitored. 1 Lawrence Road DS0000018055.V360186.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents would experience difficulty in raising any concern or making their concerns know to an independent source, but can be assured that they are protected by the home’s ‘safeguarding adults from harm procedures’. EVIDENCE: The manager advised that there has been no reported complaints since the last inspection. Residents have access to a ‘user friendly’ complaints procedure, but have very limited abilities and would not be able to raise any complaint or concern independently. Since the last inspection, the manager arranged for an advocate to visit the home. The manager understood that the advocate will not be visiting on a regular basis and would only come if asked because of a specific ‘issue’. This arrangement does not provide residents with direct access to an independent person. Residents have no family connections and the funding authority has not been unable to support the home in this matter. Staff explained how residents would (and do) express their choices and preferences of day-to-day matters. This is normally through direct observation, change of behavioural patterns or through an established non-communication process. Staff maintain good records about this. Since the last inspection, the manager has arranged for all staff to attend ‘safeguarding adults from harm’ training sessions. Staff on duty were asked about their understanding of this matter and how they would report/record any 1 Lawrence Road DS0000018055.V360186.R01.S.doc Version 5.2 Page 17 incident. Staff had a clear understanding of how they would manage this, which was in line with the home’s policy and procedure. 1 Lawrence Road DS0000018055.V360186.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable and clean environment. EVIDENCE: In February 2008, a major refurbishment programme started. The home has a new kitchen, new office, new staff toilet and utility room. A more ‘user friendly’ lounge/dining space has been created. The manager is aware that several ‘sharp corners’ on the new fitments need to be ‘rounded off’ to make them safe for residents. The door to the new staff toilet opens directly across the entrance to the residents’ bathroom/toilet which could be a hazard . It is recommended that the current situation be reviewed to make sure that unnecessary accidents don’t happen. One of the resident’s bedrooms was being decorated and partly refurbished on the day of inspection. The second bedroom will be also be redecorated and refurbished. There are plans for the garden/patio area to be made more ‘user’ friendly’ during the summer. Staff said that the refurbishment had ‘made such 1 Lawrence Road DS0000018055.V360186.R01.S.doc Version 5.2 Page 19 a difference’ and residents expressed pleasure at being able to sit in the newly created dining area to eat their lunch. Within their surveys, residents said that the home was fresh and clean. The environment on the day of inspection was warm, clean and homely. 1 Lawrence Road DS0000018055.V360186.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 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be expect to be cared for by a team of staff that is reliant on agency to maintain minimum staffing numbers. EVIDENCE: Since the last inspection no staff have left employment and none have been recruited. The home has a recruitment policy to follow should any new members of staff be recruited. The current staff rota was accurate and reflected staff on duty for the day. There are two members of staff on duty during the day and one ‘awake’ member of staff on duty at night. The home has no ‘sleeping in’ facilities for staff. Rotas show that the home is reliant on agency staff to maintain minimum staffing levels. For example, some shifts during the week are solely covered by agency staff. Currently, 60 of the total staffing establishment are agency staff. Some of the agency staff are ‘regulars’ which promotes continuity of care for residents. 1 Lawrence Road DS0000018055.V360186.R01.S.doc Version 5.2 Page 21 It was positive to note that the manager still continues to work supernumery hours. This has meant that the manager has been able to concentrate on the improved administration and documentation systems. The manager reported that the current staffing group is now more stable and all staff whether agency or permanent are expected to attend ‘house meetings’ and supervision sessions. Agency and permanent staff confirmed this practice to us. Staff told us about the current training courses they had attended or are booked to attend and the availability of the home’s manger to provide guidance and advise. A staff training programme list was available. One staff member said the manager ‘is hands on’ and this input was clearly valued. Staff also spoke of low sickness levels and good moral. The manager confirmed this. Comments with staff surveys were positive about information being available to do their job, the induction process and training opportunities. Staff reported that they knew how to make a complaint and felt there was enough staff on duty to meet the basic needs of residents. In addition, staff were positive about having the right management support. One survey reported ‘I am happy with my work’. Some comments with staff surveys reflected the findings of this inspection concerning the reliance on agency staff and felt that residents needed to have care from permanent staff. They also felt that by having so many agency staff that this put limits on how often residents could go out. The service manager told us that the home currently has two full time carer’s post vacant. There are imminent plans for advertising these posts. In the past, the home has had difficulties in recruiting new staff because of its location. We are of the view that although the home is reliant on agency staff, residents are being cared for my ‘regular faces’. In addition, the service manager assured that once the recruitment matter is addressed, agency staffing would be minimal. On this basis, we have assessed this outcome of standards as good. The situation will be assessed again at the next inspection. From observation during the day, staff on duty related well to the residents. Residents seemed at ease with all staff. 1 Lawrence Road DS0000018055.V360186.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 and 43 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect to live in a home where the local management and administration systems have improved which has had a positive impact of the day-to-day care. Residents cannot be assured that that the registered provider monitors the quality of care. EVIDENCE: The manager has been in post since May 2007 and an application for the position of registered manager is pending. During this time, there have been a number of significant improvements in the administration and documentation. At this inspection further improvements have been made. These include management monitoring tools for assessing report writing and medication administration systems. Also, in arranging for the funding local authority to conduct the very overdue residents review and being instrumental in exploring 1 Lawrence Road DS0000018055.V360186.R01.S.doc Version 5.2 Page 23 ways to enhance residents activity/leisure pursuits. The manager has also played an instrumental part in the refurbishment of the home ensuring that residents’ wishes and preferences were sought and upheld. The manager has positively acted upon the shortfalls identified at the last inspection and made good progress. Staff were very positive about the home’s management style and direction. At the last inspection safety and maintenance records were sampled and recorded to be in good order. These were not viewed again at this inspection because the manager is still in the process of receiving new ones following the recent refurbishment. They will be viewed again at the next inspection. The home has current safe working and environmental risk assessments in place. Entries in the accident/incident book reflected entries within individual resident daily records. There was evidence that the manager ‘follows up’ all entries to ensure that any incident has been managed properly. Records show that with the support of staff, residents can attend a ‘resident forum’. As mentioned previously in this report, the home should pursue an opportunity for an independent person/advocate who could visit the home for these occasions and act on behalf of a resident. At the last inspection it was identified that the home does not have a quality monitoring/quality assurance process in place. Whilst there is still no report in place, the manager has made good progress on assessing and monitoring various aspects of the home’s function. For example, there is a monitoring tool now in place to look at medication administration recording systems, accident/incident recording patterns and a log to gauge resident ‘reactions’ to newly introduced routines or experiences. We discussed with the manager national minimum standard 39 and Regulation 24 which details what is required. The manager knows that they have to consult all stakeholders about their views of the service. The manager assured that all the information collected to date and the information obtained through surveys will be collated and a report will be prepared. It is important that the registered provider through the service manager assists the manager in this process. It is a joint responsibility and cannot be left to the manager alone. On the day of this inspection a service manager was undertaking a Regulation 26 visit. The service manager confirmed the following account of the situation regarding Regulation 26 visits at the home was correct: A visit was made and a report produced on 11th November 2007 and 15th January 2008. The service manager reported that a visit to the home had been made on 7th December 2007, but the purpose of the visit was not known and no report was made. In February 2008, the home was closed for two weeks during the refurbishment. The service manager reported that a visit to the home was made in connection with the refurbishment, but no report was 1 Lawrence Road DS0000018055.V360186.R01.S.doc Version 5.2 Page 24 made. In March 2008, the service manager reported that no visit was made because of sickness and the registered provider had made no other arrangements for a visit to be undertaken. The outcome for residents is that they continue to live in a home where the registered provider does not comply with all their statutory regulatory obligations. The situation was discussed in detail with the service manager. The service manager acknowledged the repeated shortfall and said that a new system was being introduced which would prevent this ‘slippage’ happening again. The service manager agreed to write us explaining the new system but is fully aware that the findings of this inspection will be recorded, as this is the third inspection where this shortfall has been identified. The Improvement Plan submitted by the registered provided following the last inspection stated ‘service manager will ensure regular visits will continue in the home as required by CSCI’. This was not our finding at this inspection. 1 Lawrence Road DS0000018055.V360186.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 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 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 X 12 3 13 3 14 3 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 2 1 Lawrence Road DS0000018055.V360186.R01.S.doc Version 5.2 Page 26 Yes 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 Standard YA22 Regulation 22 Requirement Suitable arrangements must be put in place to ensure that residents have access to an independent person/agency. This is to ensure that residents have free access to an independent person/agency with whom they can raise any concern or complaint and who can act on their behalf and in their best interest. The previous timescale of 31/12/07 to meet this requirement has not been achieved in full. 2 YA43 26 The registered provider must demonstrate that that the home is being managed effectively and competently on a day-to-day basis for the benefit and well being of residents. For this to happen, a Regulation 26 visit (visit by person in control) must take place at least once a month and be unannounced. 02/04/08 Timescale for action 30/06/08 1 Lawrence Road DS0000018055.V360186.R01.S.doc Version 5.2 Page 27 The previous timescales of 15/05/07 and 31/12/07 to meet this requirement has not been achieved. 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 1 Lawrence Road DS0000018055.V360186.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 1 Lawrence Road DS0000018055.V360186.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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