Inspection on 18/07/06 for 16 Lumley Road

This inspection was carried out on 18th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

16 Lumley Road 26/06/07

16 Lumley Road 31/01/06

16 Lumley Road 21/06/05

16 Lumley Road 18/01/05

16 Lumley Road 06/09/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

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

CARE HOME ADULTS 18-65 Lumley Road (16) 16 Lumley Road Horley Surrey RH6 7JL Lead Inspector Joseph Croft Unannounced Inspection 18th July 2006 10:00 Lumley Road (16) DS0000013453.V303744.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 Lumley Road (16) DS0000013453.V303744.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. Lumley Road (16) DS0000013453.V303744.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lumley Road (16) Address 16 Lumley Road Horley Surrey RH6 7JL 01293 782238 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) H4037@mencap.org.uk Royal Mencap Society Mr S Chandramurthi Care Home 6 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (1) of places Lumley Road (16) DS0000013453.V303744.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 18 - 65 YEARS, EXCEPT ONE OVER THE AGE OF 65 31st January 2006 Date of last inspection Brief Description of the Service: 16 Lumley Road is a detached house developed to provide accommodation for up to eight adults with learning disabilities, one of whom may be over the age of 65. The home is set in a residential area within walking distance from Horley town centre. All bedrooms are single occupancy and are decorated to a good standard. There is a pleasant garden to the rear of the property for the service users to enjoy. The home has some off road parking. The weekly fees for the home vary from £572.45 to £786.87. Lumley Road (16) DS0000013453.V303744.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first Key Inspection using the Inspection for Better Lives process for the year 2006/2007. This key inspection ensured that all the core standards of the National Minimum Standards for Younger Adults were considered. This inspection was unannounced therefore staff and residents were not informed in advance of the inspection being carried out. The inspection process included a tour of the premises, sampling of residents’ care plans, risk assessments, staff training records and staff recruitment files; other documents sampled included policies and procedures, staff duty rota, menu, medication and records of medicines. Discussions took place with the manager, staff, and residents who were at the home at the time of the inspection. During discussions residents stated they were happy living in the home, that the food was good and they liked the activities offered. Residents’ bedrooms had their personal belongings such as televisions and pictures. Residents had been provided with a key for their bedroom doors, and were observed using these when entering their bedrooms. Residents stated that they like the staff, and that they help them to make choices regarding their daily lives. Discussions took place with staff on duty at the time of the inspection. Staff were knowledgeable about residents’ care plans, their likes and dislikes, and how to support residents. Feedback was provided at the end of the inspection to the manager. The inspector would like to thank the staff and residents for their cooperation during the inspection. What the service does well: The home continues to do well in all as identified during the previous inspection. The relationship between residents and staff continue to be relaxed and friendly. Evidence viewed indicated that residents were encouraged and supported to be as independent as they were able. Care plans and conversations with residents and staff confirmed that they each had a programme of activity, which included attending college, day care, leisure activities, and shopping, and home time for life skills development. Care plans were found to provide a good level of information about each individual, based upon a sound assessment of their needs and aspirations, with person centred care planning. Evidence gathered from discussions with staff on Lumley Road (16) DS0000013453.V303744.R01.S.doc Version 5.2 Page 6 duty, and confirmed in care plans, continue to indicate that the advice and support of relevant professionals is actively sought and acted upon. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lumley Road (16) DS0000013453.V303744.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lumley Road (16) DS0000013453.V303744.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. 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. The home has regard for ensuring written needs assessments are undertaken prior to admission to the home. EVIDENCE: The manager stated that there had not been an admission to the home since August 2002. Two residents care files were sampled as part of the inspection process. This evidenced that each resident has a care manager from whom a pre-admission assessment is obtained. These assessments included details on specific conditions, care and health needs, physical well-being, ability to recognise and report health care needs, eating, dexterity, mobility, history of falls, manual handling assessment, disabilities, waking and sleeping patterns, risks and freedom of choice. These assessments formed the basis of individual resident’s care plans. Lumley Road (16) DS0000013453.V303744.R01.S.doc Version 5.2 Page 9 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 at least once during a 12 month period. 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. The home has clear care plans and risk assessments in place that ensure the needs of the residents are met. Residents are clearly supported by the staff and have very independent and active lives. EVIDENCE: Residents’ files sampled evidenced that detailed care plans and risk assessments had been completed, and that residents and their families/advocates had signed them. Care plans sampled were detailed and clear for the reader to know how to meet the assessed needs of residents. Information in care plans included Health care needs, awareness of safety, behaviour, relationships, daily living and social needs, care support and individual goals. Care plans were also maintained in a format using pictures and words residents could understand. Evidence was viewed, through daily notes and regular reviews that care needs were being consistently met. The home has incorporated the care plans into Person Centred Plans that also includes individual’s dreams. The manager Lumley Road (16) DS0000013453.V303744.R01.S.doc Version 5.2 Page 10 stated that the home has invested in Person Centred Planning recording albums, whereby residents collect pictures and make audio recordings on each page of the album. Person Centred Plans also included a relationship circle, which identified who was important in residents’ lives. The manager stated that family and parents are encouraged to visit the home, although the aging needs of parents limit this. Staff of the home had taken residents to visit their parents, which was confirmed during discussions with residents. One resident told the inspector he had just come back from visiting his parents in Manchester, where he stayed in a hotel. The manager stated a member of staff accompanies residents when long journeys are undertaken. Minutes of resident’s meetings evidence that residents are involved in regard to making decisions that affect the running of the home and their daily lives. These are also recorded in their care plans. During discussions, residents stated they can do what they choose, which includes activities they wish to partake in and things they like to achieve. Accurate records of these were maintained in the care plans sampled. During discussions the manager and staff informed the inspector that residents enjoy an active and independent life style and freely access the community with or without the assistance of staff. It was further stated that the home only provides support to a resident if there is a perceived risk to the resident. The manager stated residents are responsible for their own finances. Residents have a building society account and a record of how much money is deposited and withdrawn from their account. Personal monies are held by the home. Records of residents’ finances were sampled; monies and receipts balanced with the records maintained. The inspector sampled risk assessments for residents; these were comprehensive and clearly detailed the potential risks, action to be taken if the resident is exposed to the risk, and the likely outcomes to the resident if no action is taken. Lumley Road (16) DS0000013453.V303744.R01.S.doc Version 5.2 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 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. Staff in the home encourage and enable residents to participate in a range of activities both within the home and the local community. The home offers a healthy balanced diet. EVIDENCE: Care plans sampled evidenced that residents were encouraged and supported to be as independent as they were able. Activities included attending clubs, day centre, work placement, leisure activities, shopping, boot sales and home time for life skills development. All residents had recently returned from a holiday in Corfu, which residents stated they thoroughly enjoyed. During discussions residents informed the inspector of the activities they enjoy, which included helping with the house chores such as cooking and cleaning. It was observed on the menu that each resident chooses a particular meal to cook for the home on one evening each week. Lumley Road (16) DS0000013453.V303744.R01.S.doc Version 5.2 Page 12 The manager stated that the residents enjoy an active and independent life style and freely access the community with or without the assistance of staff. This was confirmed during discussions with staff. The manager stated that family, advocates and friends are actively encouraged to visit the home, and residents can meet with them in the privacy of own bedrooms, and go out if they wished to. Residents are allowed to choose who they want to see. The home uses a five-week rolling menu that includes breakfast, lunch and evening meal. The menu was viewed and evidenced that balanced meals are offered to the residents, which include fresh vegetables and fruit. As stated earlier, residents take it in turn to help prepare and cook a meal of their choosing. The kitchen in the home has recently been refurbished throughout, and provides pleasant facilities for the preparation and cooking of food. Food stores were viewed and evidenced that food is appropriately stored. Residents can eat their meals wherever they choose, and the home has a suitably furbished dining room. During discussions, residents stated they like the food, and were proud that they are able to choose menus and help with the cooking. Evidence was viewed in the minutes of residents meetings that meals and food are always discussed, and allowing the residents to choose the foods they would like to eat. The manager stated when residents do not like a particular days menu, an alternative meal is offered; evidence of records of these were observed in the daily notes. Residents’ nutritional needs are regularly assessed and records are maintained in individual care plans. Lumley Road (16) DS0000013453.V303744.R01.S.doc Version 5.2 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents personal care is promoted by the home, however health care needs are not being fully met. Residents are protected by a robust medication policy and procedure, but training for all staff in this area is required. EVIDENCE: The care plans and risk assessments evidenced that the majority of the service users are able to care for themselves but where necessary staff members will assist them. Risk assessments included risks on falls, bathing, absconding and fire alarm. However, it was noted that there were no risk assessments in place for residents with diabetes or epilepsy. Requirements have been made in regard to these. All residents are able to attend to their personal care without the support of staff. The manager stated baths are monitored to ensure residents are bathing and taking care of their personal needs. Bedtimes are flexible, as is rising in the morning. During discussions, residents stated they go to bed when they are tired and get up when they are ready. During the inspection, it was observed that residents were dressed in their own clothes. Lumley Road (16) DS0000013453.V303744.R01.S.doc Version 5.2 Page 14 Residents are allotted a key worker who has the over all responsibility for ensuring the assessed needs of residents are being met. During discussions, staff were able to give accurate accounts of the contents of care plans for the residents who they key work with. Arrangements regarding areas of health care are detailed in residents care plans. Records of visits by the GP, and attendance to the Dentist, Opticians, Diabetic clinic, Chiropodist, and other health care professionals are also maintained. Residents have access to all NHS healthcare facilities as required. It was noted that two residents are diabetic, and sugar levels are monitored and recorded for each in their care plans. However, it was noted that staff had not received formal training in regard to diabetes. A requirement has been made in regard to this. The home uses the Mencap Medical Policy and Procedure that is followed by staff. The manager stated that none of the residents administer their own medication. The home currently does not have a resident who is taking a prescribed controlled drug. Training records in the Safe Administration of Medication for staff who dispense medication were viewed. These evidenced that only two members of staff had received this training. The manager stated he was undertaking an assessment of each member of staff in regard to their training in this area; however, the manager stated that he had not received training on the Safe Administration of Medicines. An immediate requirement has been made that all staff, including the manager, must receive training in the Safe Administration of Medication. Medical records sampled provided evidence that accurate records of medicines dispensed are clearly maintained. The home maintains records of medicines received and returned to the Pharmacist. Evidence was viewed that the Pharmacist visits the home on a six monthly basis to provide advice and check the storage of medicines. Lumley Road (16) DS0000013453.V303744.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system to enable residents and their families to raise concerns. Residents are protected by staff having knowledge and understanding of adult protection issues. EVIDENCE: The home uses the Mencap Complaints Policy and Procedure. The Policies provide the timescales for responding to complainants, and includes the contact details for the Commission For Social Care Inspection Surrey Local Office. During discussions, residents stated they would talk to staff if they were unhappy or wanted to make a complaint. The complaints book was viewed and evidenced there had been no complaints made since last inspection. Staff spoken to stated that they had read and understood the Complaints Policy and Procedure, and gave an accurate account of whom they would report complaints to. The home follows the Mencap Protection of Vulnerable Adults Policies and Procedures; however, the copy held in the home was dated October 2002. The manager was able to obtain an updated version from Mencap during the inspection. This was dated October 2004. During discussions staff gave an accurate account of what to do if they witnessed or suspected that a resident is being, or had been abused. Staff reported they would have no hesitation reporting bad practice, and if necessary, they would report their concerns to the Commission For Social Care Lumley Road (16) DS0000013453.V303744.R01.S.doc Version 5.2 Page 16 Inspection Surrey Local Office. Evidence of staff training in the Protection of Vulnerable Adults was observed. The manager and another member of staff attended the Surrey Multi-Agency training in the Protection of Vulnerable Adults on the 10th March 2006. Evidence was observed that the manager had delivered in-house training on the Protection of Vulnerable Adults to all other staff working at the home. Lumley Road (16) DS0000013453.V303744.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment was pleasant and generally met the necessary standards, however, certain areas require attention to make the home a more pleasant and comfortable place to live. EVIDENCE: The inspector was given a tour of the premises by one of the residents. The environment was clean, tidy and spacious. Residents had unrestricted access to all communal parts of the home. Residents have single bedroom accommodation that contains a sink, bed, chest of drawers, wardrobes, TV, lockable cupboards and their own personal possessions. All residents have their own key for their bedrooms. It was noted that the toilet on the first floor had a malodour. An immediate requirement has been made that this must be investigated and resolved. The bathroom on the first floor required attention to the décor, as the paintwork Lumley Road (16) DS0000013453.V303744.R01.S.doc Version 5.2 Page 18 was beginning to flake away, and the air vent in the bathroom had gathered dust. Requirements have been made in regard to these. It was also noted that the airing cupboard in the bathroom did not have a lock fitted, which left this accessible to residents, and therefore posed a risk to their health and safety. An immediate requirement has been made that the registered person must write a risk assessment in regard to this, and forward a copy to the Commission For Social Care Inspection Surrey Local Office. The home has a separate dining room with two tables and adequate seating for residents to enjoy their meals in comfort and appropriately furnished surroundings. The kitchen had recently been refurbished and was bright and very clean. Food was stored appropriately in the kitchen units and fridge/freezers. It was observed that the Control Of Substances Hazardous to Health cupboard on the ground floor had been left unlocked throughout the duration of the inspection. An immediate requirement has been made in regard to this. There is a spacious and appropriately maintained garden to the rear of the premises where residents can enjoy sitting out, having BBQs and attend to the garden plants. During discussions residents stated they like living at the home, it is always clean and tidy, and they like having their own bedrooms. Lumley Road (16) DS0000013453.V303744.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported and protected by the home’s recruitment procedure. Mencap has regard to ensuring staff receive appropriate training. EVIDENCE: During the inspection staff were observed to interact with the residents in a professional and caring manner. The relationship between residents and staff was relaxed and friendly. Residents were observed communicating with staff, and being accompanied to activities and appointments outside of the home. The staff duty rota was viewed for the week of the inspection. This evidenced that there was one member of staff on duty from 7am to 14:00, and one member of staff on duty from 14:00 to 22:00hrs. A carer sleeping in provides night cover. The manager stated that residents do not require support with personal care, and are self-sufficient. However, the manager has been asked to undertake a review of the staffing arrangements for the home to ensure there are appropriate numbers of staff on duty to meet the assessed needs of the residents. The manager stated the home does not use agency staff, and the home’s staff and/or bank staff provided by Mencap cover staff absences. Lumley Road (16) DS0000013453.V303744.R01.S.doc Version 5.2 Page 20 The manager stated that three members of staff hold the NVQ level 2 in care, and that all new staff undertake an induction programme. These were evidenced in staff files. The home follows the Mencap Recruitment Policies and Procedures, which were viewed during the inspection. The policy included necessary information in regard to references, Criminal Record Bureau and Protection of Vulnerable Adults first checks. The Policies and Procedures were dated October 2003. Staff recruitment files were sampled during this inspection, and were found to contain the appropriate documents as stated in the National Minimum Standards, with references and checks being undertaken. The manager stated that the residents are part of the recruitment process, in that one resident will be part of the interview panel. The training and development of staff continues to progress, however, training in regard to medication has been addressed under Standard 20. Staff training records were sampled and evidenced that all other mandatory training had being provided. Lumley Road (16) DS0000013453.V303744.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was evidence of areas of good management and practice within the home; however, some issues in regard to health and safety must be addressed. EVIDENCE: The manager stated he had been working at the home for twelve years. The manager has achieved the Registered Managers Award (RMA) in February 2005, and was commended on this achievement. The manager also had training in First Aid 30/1/04, The D32 and D33 assessors award, Manual Handling, 1/9/04, Food Hygiene, 20/02/04, Health and Safety, 24/2/04, and attended the Surrey Multi Agency training on the Protection of Vulnerable Adults, 10/03/06. The home has an annual development plan that was viewed during the inspection. Lumley Road (16) DS0000013453.V303744.R01.S.doc Version 5.2 Page 22 Quality assurance surveys were viewed, these evidenced that the home’s management seeks the views of residents and their families/advocates. Hyde Housing Association own the property and therefore developed their own annual development plan. Staff training records sampled evidenced the following mandatory training had been undertaken: Manual Handling, 1/02/06, First Aid, 21/3/06, Food Hygiene, 12/10/04, Surrey Multi-Agency training in the Protection of Vulnerable Adults, 10/03/06, Health and Safety, 11/10/02 and in house training on fire, 5/2/06. A requirement in regard to training in medication has been made under Standard 20. The following health and safety checks of the home were evidenced: Fire Test 8/7/06, last full evacuation – 26/5/06, monthly emergency light testing last carried out on 17/6/06, Fire alarm installations, 22/5/06 and the fire extinguishers were serviced on 22/02/06, and Fire safety risk assessments, last reviewed on the 17/04/06. Health and Safety checks are undertaken on a monthly basis, the last Health and Safety report was viewed, dated 10/07/06. Annual records were viewed for Legionella testing, portable electrical appliance testing, gas safety, and the Employers liability insurance, which expires on the 31/05/07. The home had an incident that was reported under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations on the 29th April 2006 in regard to a faulty shower. This was followed by the Environmental Health Office inspection on the 11/05/06, and was drawn to a satisfactory conclusion. Lumley Road (16) DS0000013453.V303744.R01.S.doc Version 5.2 Page 23 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 3 27 2 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X 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 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 3 X X 3 X Lumley Road (16) DS0000013453.V303744.R01.S.doc Version 5.2 Page 24 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 YA19 Regulation Requirement Timescale for action 25/07/06 2 3 YA19 YA20 4 5 6 YA27 YA27 YA27 7 YA30 8 YA33 13 (4) (c ) The registered person must ensure that written risk assessments in regard to diabetes and epilepsy are produced. 18 (1) (c ) The registered person must (i) provide training to all staff in regard to diabetes. 18 (1) (c ) The registered provider must (i) ensure all staff, including the manager, attend training in the Safe Administration of Medicines. 16 (2) (k) The registered person must ensure the malodour in the toilet on the first floor is resolved. 23 (2) (b) The registered person must ensure the décor of the first floor bathroom is attended to. 13 (4) (c ) The registered person must write a risk assessment in regard to access to the airing cupboard, and forward a copy to the Commission For Social Care Inspection Surrey Local Office. 13 (4) (c) The registered person must ensure the Control of Substances Hazardous to Health cupboard be locked at all times. 18 (1) (a) The manager must undertake a review of staffing levels to DS0000013453.V303744.R01.S.doc 18/09/06 18/07/06 18/07/06 18/08/06 18/07/06 18/07/06 18/08/06 Lumley Road (16) Version 5.2 Page 25 ensure there are sufficient numbers of staff on duty to meet the assessed needs of residents, and forward a copy to the Commission For Social Care Inspection Surrey Local Office. 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 Lumley Road (16) DS0000013453.V303744.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 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 Lumley Road (16) DS0000013453.V303744.R01.S.doc Version 5.2 Page 27 - 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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