Inspection on 17/07/07 for Ambleside Lodge

This inspection was carried out on 17th July 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ambleside Lodge 19/10/06

Ambleside Lodge 24/01/06

Ambleside Lodge 20/06/05

Ambleside Lodge 27/01/05

Ambleside Lodge 23/06/04

Ambleside Lodge 29/01/04

Ambleside Lodge 03/10/03

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Ambleside Lodge 25 Ambleside Avenue London SW16 1QE Lead Inspector Sonia McKay Key Unannounced Inspection 17th July 2007 09:15 Ambleside Lodge DS0000022780.V341893.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 Ambleside Lodge DS0000022780.V341893.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. Ambleside Lodge DS0000022780.V341893.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ambleside Lodge Address 25 Ambleside Avenue London SW16 1QE 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 8677 9175 020 8677 9175 amblesidelodge@fairdasl.co.uk Mr Basdeo Kaydoo Mrs Danon Lutchmee Kaydoo Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places Ambleside Lodge DS0000022780.V341893.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th October 2006 Brief Description of the Service: Ambleside Lodge is a privately run staffed home for adults with mental health issues. It is located a short walk from Streatham High Road which has many amenities and good transport links. There is on road parking nearby and off road parking in front of the home. The home provides accommodation and support for six service users. There is a lounge diner, kitchen and laundry room and each service user has their own bedroom, there is also a back garden. Prospective service users are given a copy of the Service Users Guide that gives information about the home and the services provided. A copy of the most recent CSCI inspection report is available in the home on request. Fees start from £850.00 per week upwards according to individual care needs. Ambleside Lodge DS0000022780.V341893.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit began at 09.15 a.m. and was completed in three hours. The inspection consisted of discussion with the registered providers who were on duty on the day of the inspection. The inspector was unable to meet with anybody using the service on this occasion, as the three people currently living in the home were engaged in their daily activities. The Commission required the registered manager complete a written assessment of the service provided (an Annual Quality Assurance Audit sometimes called an AQAA). Information supplied in this self-assessment is used to inform this report. What the service does well: What has improved since the last inspection? Written plans for the care of new residents are available and include information about any risks to their safety and welfare. The visitor’s policy has been revised to allow residents to maintain and develop intimate relationships whilst living in the home if they wish. This was done in consultation with the residents themselves. Ambleside Lodge DS0000022780.V341893.R01.S.doc Version 5.2 Page 6 Steps have been taken to improve health and safety. Window opening restrictors have been fitted and hot water temperatures restricted to within safe limits. All staff now have a recent and satisfactory criminal records check in place. There is conservatory built for residents to enjoy and to provide a smoking area, in accordance with recent changes in legislation. There is a new kitchen, shower room and laundry room on the ground floor. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ambleside Lodge DS0000022780.V341893.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 Ambleside Lodge DS0000022780.V341893.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have adequate information about the services provided in the home and their individual needs and aspirations are assessed and recorded in a written plan. People have an opportunity to visit the home for a trial period before making a decision to move in. EVIDENCE: There are two documents that provide information about the service provided, a statement of purpose and a service users guide. The service users guide contains a summary of the information provided in the statement of purpose and additional information about the services provided, the home environment and the outcomes of resident satisfaction surveys. The ‘Service Users guide and associated individual contracts must provide greater detail relating to the standard package of services provided. The terms and conditions (including fee levels) that apply to key services (both personal care and food) and the payment arrangements (resident contribution/local authority contribution) must be stipulated. Ambleside Lodge DS0000022780.V341893.R01.S.doc Version 5.2 Page 9 The guide must also state whether the terms and conditions (including fees) would be different in circumstances where a person’s care is funded, in whole or in part, by someone other than the resident. (See requirement 1) The registered home manager liaises with the placing authority and health teams when a prospective resident is referred. This involves visiting the person, meeting with psychiatric health professionals and reading any hospital assessments and reports available. Records relating to recent admissions are detailed and involve the completion of an application form by a psychiatric nurse, completion of a written ‘preadmission assessment of needs’ by the home manager and obtaining hospital psychiatric assessment reports. A pre inspection document completed by the home manager indicates a need for improvement in the speed with which initial care plans are formulated with each new resident. Care plans examined during this inspection indicate that initial care plans and risk assessments are in place for newer residents. A previous requirement to this end is therefore met. Prospective residents are offered an opportunity to visit the home before making a decision to move in for a trial period. Ambleside Lodge DS0000022780.V341893.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. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Assessed and changing needs are reflected in individual plans for each persons care. Residents are encouraged and supported to make decisions about their lives and risk assessment is used to keep people as safe as possible without reducing their independence. EVIDENCE: Written plans for care focus on mental health, physical needs, daily living skills, social networks, cultural needs, employment and therapeutic activity, finance and budgeting and accommodation and future placements. Residents are involved in the formulation of their own plan and the documents are signed by the resident and the home manager. Some residents also add their own comments. The care plan identifies goals in each area and how these goals are to be achieved. The care plans examined included goals and decisions made in C.P.A meetings. Ambleside Lodge DS0000022780.V341893.R01.S.doc Version 5.2 Page 11 Care plans in place have been evaluated regularly and revised to reflect the achievement of existing goals and the setting of new goals. Care plans also reflect any restriction or condition imposed under terms of hospital discharge, such as submitting to regular blood tests or treatment. These individualised plans enable residents to benefit from a dynamic care planning process with goals that change as each person develops greater independence. A risk assessment tool is used to document risks around each individual and the home manager retains copies of all C.P.A meeting minutes that provide detailed risk management strategies and crisis interventions plans. Residents are encouraged to make decisions, subject to any individual restrictions in place, in accordance with any supervision arrangements agreed during discharge from hospital and in the C.P.A process. Residents are generally responsible for their own finances and benefit claims, although it is noted that staff accompany residents to appointments at the benefits agency if they are unable to do so without support. Some residents also require advice and support to budget their money, although no money or valuables are currently held in safekeeping by staff. There is a useful folder containing contact information for local and national advocacy services. The folder, which is available in a communal area, also contains information about other health services, education and employment and leisure facilities in the area. Ambleside Lodge DS0000022780.V341893.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, 15, 16 & 17. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People living in the home have opportunities for personal development and leisure activities. They are able to maintain friendships and relationships and to choose and assist with preparing meals that are chosen and culturally appropriate. EVIDENCE: There are currently three people living at Ambleside lodge. People engage in their own preferred daytime activities. These activities include supported employment training and attending day services and social groups for specific cultural and ethnic groups. One resident recently had a month long holiday visiting family in the Caribbean. Ambleside Lodge DS0000022780.V341893.R01.S.doc Version 5.2 Page 13 There is opportunity for people to practice their religious beliefs if they wish and to attend places of worship in the local area, which is culturally and religiously diverse. The staff team includes individual staff members who are of the same culture and ethnicity as individuals within the group of service users. This diversity is also reflective of the local community. The names of all residents are added to the electoral role so that they have the opportunity to vote in elections should they wish to. House rules are clearly stated in the contract that each resident signs when they move in to the home. People are permitted to have social visits in the privacy of their own bedrooms within reasonable parameters of safety and good behaviour. Visiting times are generally restricted to before 9.00 p.m. In the previous inspection report a recommendation was made to review this policy/rule so that people can have an opportunity to develop an intimate personal relationship if they wish. The registered manager discussed the rule with residents during one of the regular group meetings and the rule has been changed so that people can now have an overnight guest provided that staff are informed and rules around general conduct and behaviour are adhered to by the visitor. This is an improvement. A record of menus examined indicated that a range of culturally appropriate evening meals are prepared and served in the communal lounge-diner. Breakfasts and lunches are prepared individually during the week as people are often out. Residents said that the food was good during the October 2006 inspection visit. To ensure that people have meals of their choice, a blank menu is distributed each week for people fill in with meals of their choosing. Residents are given responsibility for chores in the home and each takes a turn to cook or assist with cooking (depending on their level of skill and independence) set the dining table and wash up dishes. Residents preparing to leave the home are encouraged to shop and prepare some of their own meals independently. Ambleside Lodge DS0000022780.V341893.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 & 20. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People receive personal support in the way they require; this support is most often minimal. Physical and emotional healthcare needs are documented and addressed, although more could be done to promote preventative healthcare. People are able to take control of their own medication where possible although more should be done to make this process as safe as possible. EVIDENCE: People generally manage their own personal care without more than verbal prompting and encouragement. A psychiatrist has been allocated to the home by the local forensic team. The allocated psychiatrist and CPN visit the people living in the home on a regular basis. Individual consultations are held in private. The registered manager said that having these consultations at the home instead of the hospital outpatients department has increased the communication between the health professionals and the home staff. Ambleside Lodge DS0000022780.V341893.R01.S.doc Version 5.2 Page 15 The manager has also introduced a system of recording for monitoring the mental health of each service user on a daily basis. Known physical health needs are well documented and are detailed in individual care plans. Each resident is registered with a local GP. The results of health appointments are recorded in care notes, although people are encouraged to be responsible for their own physical health where possible, and generally attend appointments without staff support. There is a need for some planning around pro-active and preventative physical healthcare and health screening, as this area of healthcare is not routinely addressed. (See recommendation 1) Medication is stored in a lockable, wall-mounted steel cabinet in the staff office. Patient information leaflets about all of the medicines in use in the home are kept to provide staff with information about possible side effects. The medication policy includes all recommended topics (including leave medication, refusals and PRN or ‘as required’ medication). A photograph of each resident is available and is attached to the relevant medication administration record. MAR charts examined show that there are no gaps in recording and all prescribed medication is in stock. There is a sample signature list for each member of staff involved in medication administration. A small supply of home remedies is available (overthe-counter analgesics) and staff have been trained in the safe administration of medication. Justified medication stock checks are completed each week. Stock numbers and outcomes of these checks are recorded. The registered manager is currently dispensing medication into weekly dose boxes for people who are beginning to self medicate. A week’s supply is dispensed at a time. The AQAA states that this is an area that the home has improved on recently. One resident was supported to become self-medicating so that he could go away on holiday to visit family overseas for a month. Whilst this is an improvement, the home staff are not qualified to dispense medication into the weekly dose boxes, this should be done by a pharmacist. (See recommendation 2) The medication administration records are not pre-printed by the pharmacy, instead the home manager is writing the names of the medications and the dosages by hand. This can lead to errors and MAR charts should be preprinted by the pharmacy. (See recommendation 3) Ambleside Lodge DS0000022780.V341893.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 & 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are opportunities for people to express their views and make complaints, although there is a need to ensure effective and independent review of the outcomes of any complaints and their investigation. Procedures are in place to ensure that residents are protected from abuse and self-harm. EVIDENCE: The complaints policy and procedure meets the standard and is distributed to people in the service users’ guide. A copy is also available in the reception area. The record of complaints indicated that no new complaints had been made to the home since the last inspection visit. During the October 2006 inspection a resident said that if he had a complaint he would relate it to the home manager directly and felt able to do so. A loose-leaf complaints form had been introduced by the home manager to enable people to write their complaint without having to relate it directly to staff if they wished. There are also regular and recorded group ‘house meetings’ and individual ‘key-work’ meetings during which people can raise concerns. The home has an adult protection policy with a flow chart to enable staff to know what to do quickly if needed. The policy included information on the need to contact the local authority and the CSCI in cases of suspected abuse. Ambleside Lodge DS0000022780.V341893.R01.S.doc Version 5.2 Page 17 The manager has knowledge of the Protection of Vulnerable Adults list (POVA) of people who should not work with vulnerable adults. The home manager said that the home does not use physical restraint. Whistle blowing training is provided as part of staff induction training. Staff have attended abuse awareness’ training. The home manager has obtained a copy of the revised adult protection procedures recently published by Lambeth social services. No recent accidents or incidents are recorded, although records for entries are available. Given that the registered provider and registered manager are the owners of the home and also work in the home on a day to day basis, there is a need to ensure that a complaint about the running of the home or their conduct can be reviewed and/or investigated by someone more independent of the service (See recommendation 4). Ambleside Lodge DS0000022780.V341893.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 & 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 safe environment and the home is clean and hygienic. EVIDENCE: The small detached house blends into the local community setting. It is located close to public transport routes, shops and leisure facilities. The communal areas of the home (lounge-diner and hallways) have recently been redecorated and new double glazed windows have been fitted. The home is well furnished and is clean and free from offensive odours. There is a small rear garden with attractive garden plants and trees. The registered providers have recently removed a garage, utility area and food storage room on the ground floor of the home and built a new laundry area, Ambleside Lodge DS0000022780.V341893.R01.S.doc Version 5.2 Page 19 kitchen, conservatory (smoking room), shower room with W.C and an additional bedroom. The communal lounge has been extended and there are new patio doors and a patio area, with plans to build another conservatory. This will be of benefit as a smoking area as presently there are no smoke free communal areas. Each person has a single furnished bedroom. All doors are fitted with an appropriate privacy lock with an over-ride facility for use in an emergency. Environmental health inspectors had visited the home to inspect the kitchen in March 2005. Their report recommends a hazard analysis and written procedures. This is now in place. During the previous inspection a number of health and safety issues were noted, fire doors were wedged open, a garden shed containing household chemicals was unlocked and window restrictors were missing from a recently replaced bathroom window on the first floor. During this inspection it is noted that COSHH materials are safely locked away (substances hazardous to health, like chemicals) and fire doors are not wedged open. Window restrictors are fitted to all windows above the ground floor. The requirements made in this regard are therefore met. Ambleside Lodge DS0000022780.V341893.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, 33, 34 & 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is very much a family run business, with the registered providers both working with residents on a day-to-day basis. There is a need to recruit and develop a larger team and to retain complete evidence of thorough recruitment checks. EVIDENCE: There are currently two newly recruited full time staff and four part time staff in addition to the registered provider and manager who work in the home on a day-to-day basis. The registered providers have been unable to establish a larger team due to the financial implications of low occupancy. Recruitment of another full time member of staff is currently underway. There are two staff on duty at all times. At night there is one member of staff awake and another asleep, but available in an emergency. There is a bedroom for staff and a small but well equipped staff office. The registered providers are on call at all times in case of an emergency. Ambleside Lodge DS0000022780.V341893.R01.S.doc Version 5.2 Page 21 • • 2 staff have an NVQ level 2 or above (a national vocation qualification in providing care) 4 staff are working to obtain this qualification The registered manager said that induction training is in accordance with Skills for Care training targets, although individual induction records could not be examined as they are held by staff currently working through them. A training plan for 2007- 2008 is in place and includes: • Mental health • Moving and handling • Fire safety • Food hygiene • Safe handling of medicines • Abuse and whistle blowing • Health and safety • Fire safety • Vocational qualifications in care A training needs analysis was completed by a training organisation in February 2007. The report of this review is available and recommends pay scale increments for training and/or achievement as a means towards increased staff retention. The registered manager said that poor staff retention has been costly, as staff tend to leave after receiving training. The registered persons should ensure that all staff receive training in equal opportunities, disability equalities issues, race quality and anti racism training. (See recommendation 5) The registered persons should ensure that a qualified First Aid trained staff is on duty at all times. (See recommendation 6) Overall there is a need to develop a team that is qualified and large enough to support the six residents that this service is registered to accommodate. Recruitment records for recently appointed staff show that enhanced criminal records checks have been obtained, as required in the previous inspection report. Recruitment records do not contain copies of proof of address in some cases, although the registered manager said that she saw evidence but did not keep copies. (See requirement 2) Ambleside Lodge DS0000022780.V341893.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. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is well run with both registered providers closely involved in the day-to-day operation and care provision. There is clear leadership and people using the service are able to contribute their ideas and views and change the way the home operates. Systems are in place to monitor the quality of service provided and to maintain health and safety. EVIDENCE: The registered providers are involved in the day-to-day running of the home. One of the registered providers is also the registered home manager. Both individuals work shifts with the residents and know them well. Both are nursing qualified and experienced in working with people with mental illness. The registered manager has completed an NVQ at level 4 and an RMA Ambleside Lodge DS0000022780.V341893.R01.S.doc Version 5.2 Page 23 and the registered provider is currently undertaking the award. Both attend training to keep them up to date with current good practice. Recent training attended includes equalities and diversity training. There is regular consultation with residents through house meetings and quality assurance questionnaires, the results of which are published in people are consulted about household issues and staffing arrangements. The registered provider arranged for a registered care manager from another company to visit the home and conduct annual quality assurance inspections on the service provided at Ambleside Lodge. The reports of these inspections are available in the home. The most recent inspection took place in March 2007 and concludes that the service provided is satisfactory. Fire detection and fire fighting equipment are in place. Visual inspections and fire alarm call point tests are conducted by staff during regular health and safety checks and professional checks are conducted periodically. Fire evacuation drills are conducted with the required frequency and when a new person moves into the home. COSHH (substances hazardous to health) materials are safely stored. Sharp knives are counted daily and stored securely in accordance with environmental risk assessments. The AQAA indicates that professional tests have been conducted on gas and electrical appliances. The home manager said that the thermostatic control valves had been fitted to all hot water outlets (other than the kitchen and laundry area) as required in the previous inspection report. Records are kept of hot water temperatures to prevent scalding and ensure that hot water temperatures are adequate. Temperatures are kept of cold food storage. The registered providers have responded promptly to requirements made by the Commission and there are no unmet requirements from previous inspection reports. Ambleside Lodge DS0000022780.V341893.R01.S.doc Version 5.2 Page 24 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 2 2 3 3 X 4 3 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 2 33 2 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 3 2 X 3 X 3 X X 3 X Ambleside Lodge DS0000022780.V341893.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 5 Requirement The registered person must revise the service users guide in accordance with recent changes in legislation. The registered persons must retain evidence of all recruitment checks required by regulation, including proof of address. Timescale for action 31/10/07 2. YA34 19 17/08/07 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 2. 3. Refer to Standard YA19 YA20 YA20 Good Practice Recommendations The registered persons should develop plans to assist people with pro-active and preventative healthcare (such as routine health screenings). The registered persons should not fill measured dose medication containers themselves. A pharmacist should do this. The registered persons should arrange for pre-printed medication administration records from a pharmacy, rather than handwriting the information about dosages themselves. The registered persons should consider how the complaints DS0000022780.V341893.R01.S.doc Version 5.2 Page 26 4. YA22 Ambleside Lodge 5. 6. YA35 YA35 procedure could be revised to include independent review as the owners work in the home on a day-to-day basis. The registered persons should ensure that all staff receive training in equal opportunities, disability equalities issues, race quality and anti racism training. The registered persons should ensure that a qualified First Aid trained staff is on duty at all times. Ambleside Lodge DS0000022780.V341893.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Ambleside Lodge DS0000022780.V341893.R01.S.doc Version 5.2 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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