Inspection on 19/10/06 for Ambleside Lodge

This inspection was carried out on 19th October 2006.

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 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ambleside Lodge 17/07/07

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 Unannounced Inspection 19th October 2006 09:00 Ambleside Lodge DS0000022780.V315899.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.V315899.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.V315899.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.V315899.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th January 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.V315899.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out in 4.5 hours over one day. It involved talking with the registered home manager and two of the five service users. Records relating to individual care arrangements, staff recruitment and training and health and safety were examined and there was a tour of the premises. What the service does well: What has improved since the last inspection? What they could do better: Service users moving into the home must be involved in making initial plans for how they will be cared for and the manager must obtain adequate information from the placing authorities before offering placements. Ambleside Lodge DS0000022780.V315899.R01.S.doc Version 5.2 Page 6 Some areas of safety in the home environment must be improved. The home manager must ensure all required recruitment checks are conducted on staff working in the home and on any new staff employed. Up to date criminal records checks must be obtained in all cases. 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.V315899.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.V315899.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 adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users have the information they need to make an informed choice about moving to the home, and they have an opportunity to visit and ‘test drive’ the service before moving in for a trial period. Although there is a good system for pre-admission assessment of care needs and risks this system has not been followed for all admissions, placing service users and staff at risk. 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 document and additional information about the services provided, the home environment and the outcomes of satisfaction surveys of current and previous service users. Both documents contain all information required by Care Homes Regulation and both were reviewed in May 2006 to reflect a recent increase in the number of service users that can be accommodated (from 5 to 6). Ambleside Lodge DS0000022780.V315899.R01.S.doc Version 5.2 Page 9 Service users are admitted from a local hospital for a period of rehabilitation in preparation for greater independence. The registered home manager liaises with the placing authority and health teams when a new service user is referred. This involves visiting the ward and meeting with the service user and psychiatric health professionals and reading any assessments and reports available. There have been two admissions since the last inspection in January 2006. Documents relating to the pre-admission assessment of the care needs of both service users were examined. Records relating to one admission were detailed and involved 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 and copies of recent C.P.A (Care Programme Approach) reviews. Records relating to a second, more recent admission are incomplete. The manager has completed a brief assessment of needs based on a meeting with the service user and has also met with the health teams involved in the individuals psychiatric care and read written information held at the hospital, but (C.P.A) information has not been obtained from the placing authority. The service user is currently on a two-week trial placement. There is no initial care plan or risk assessment in place, and no written evidence of discussion and agreement of any restrictions and plans that may become permanent. (See requirement 1). Both service users have visited the service before making a decision to move in for a trial period. Ambleside Lodge DS0000022780.V315899.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 adequate. This judgement has been made using available evidence including a visit to this service. Individual and changing are needs are generally reflected in individually written plans for care, although failure to ensure that a new service user has a written plan that he has agreed has affected the scoring of standards 6 and 7. There is evidence of close liaison with health professionals responsible for supervised hospital discharges but a failure to ensure that risks are accurately documented in written assessments. EVIDENCE: The home manager has devised and introduced a new individual care-planning format. These written plans 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. Each service user has signed their respective plans and in some cases have also added their own comments. Ambleside Lodge DS0000022780.V315899.R01.S.doc Version 5.2 Page 11 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. These plans are a useful tool for staff that are assisting service users to move towards more independent living. Three service users have recently moved to less supported accommodation. Care plans in place have been evaluated regularly and revised to reflect the achievement of existing goals and the setting of new goals (as required in the previous inspection report). These individualised plans enable service users to benefit from a dynamic care planning process with goals that change as service users develop their independent living skills. One new service user does not have an initial care plan in place. The terms of hospital discharge include residing at the home and being accessible to the community forensic outreach team. It is important that service users have a clear understanding of the conditions of the placement at the home and that these conditions are clearly outlined in a care plan that is discussed and agreed with the service user. (See requirement 2). 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. However, risks relating to two new service users are inadequately documented and in some cases do not correspond to risks identified in documents obtained from health authorities. For example, one service user has a history that includes aggression towards staff when mentally unwell or refusing medication, although the homes own risk assessment does not identify this. (See requirement 1). Service users 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. Generally service user choose their day to day activities, are responsible for applying for and budgeting any state benefits (with support to complete applications and budget as necessary) and as a group decide on menus in the home. 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. Ambleside Lodge DS0000022780.V315899.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): 11, 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. Service users have opportunities for personal development and can take part in peer, age and culturally appropriate activities if they wish. There is good access to local community facilities and services. Visiting times are restricted and this may impinge on the ability of service users to develop intimate relationships if they wish. Service users rights are respected and responsibilities recognised in their daily lives and they enjoy their meals and mealtimes. EVIDENCE: There are currently five service users living in the home. Four service users attend a daycentre for African Caribbean adults who use mental health services. There are currently events being held at the club to celebrate Black History month. One service user recently enjoyed a weeklong holiday arranged by the daycentre. Ambleside Lodge DS0000022780.V315899.R01.S.doc Version 5.2 Page 13 One service user attends college to study electrical installation and one service user attends a rehabilitation daycentre to develop employment skills. One service user has recently applied to do voluntary work in a local library. There is opportunity for service users 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 service users are added to the electoral role. Service users are permitted to have social visits in the privacy of their own bedrooms within reasonable parameters of safety and good behaviour. Visiting times are restricted to before 9.00 p.m. This is clearly stated in the house rules, but may not provide service users with an opportunity to develop an intimate personal relationship if they wish. (See recommendation 1). 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. A service user said, “ The meals are excellent and we can make our own meals as well”. To ensure that service users have meals of their choice, a blank menu is distributed each week for service users to fill in with meals of their choosing. Service users are given responsibility for chores in the home and each takes a turn to cook, set the dining table and wash up dishes. Service users preparing to leave the home are encouraged to shop and prepare some of their own meals independently, as recommended in the previous inspection report. Each service user has a key to the front door and to their bedroom door. A service user confirmed that staff address him politely and respectfully, always knock on his bedroom door before entering and he receives his post unopened. Ambleside Lodge DS0000022780.V315899.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. The physical and emotional health care needs of service users are met and service users are protected by the homes policies and procedures for dealing with medicines. EVIDENCE: Service users are able to manage their own personal care. The home manager liaises with the local CMHT (Community Mental Health Teams). C.P.Ns (Community Psychiatric Nurses) visit service users living at the home on a regular basis. The manager has also introduced a system of recording for monitoring the mental health of each service user on a daily basis. Physical health needs are well documented and are detailed in individual care plans. Each service user is registered with a local GP. The results of health appointments are recorded in care notes, although service users are Ambleside Lodge DS0000022780.V315899.R01.S.doc Version 5.2 Page 15 encouraged to be responsible for their own physical health where possible, and generally attend appointments without staff support. Medication is held 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). Pharmacy generated Medication Administration Records (M.A.R charts) are well maintained with no gaps in recording. A photograph of each service user is available and is attached to the relevant chart. 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, as recommended in the previous inspection report. Ambleside Lodge DS0000022780.V315899.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 good. This judgement has been made using available evidence including a visit to this service. Service users feel their views are listened to and acted upon and they are protected from abuse, neglect and self-harm. EVIDENCE: The complaints policy and procedure meets the standard and is distributed to service users 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. A service user 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 service users 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 service users 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. The manager has knowledge of the Protection of Vulnerable Adults list (POVA) of people who should not work with vulnerable adults. Ambleside Lodge DS0000022780.V315899.R01.S.doc Version 5.2 Page 17 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. Ambleside Lodge DS0000022780.V315899.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, 25, 27 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is comfortable but more must be done to ensure safety. Each service user has a single bedroom and there a re sufficient bathroom facilities. The home is clean and free from offensive odours. 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. 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 and an additional bedroom. The communal lounge has been extended and there are new patio doors and a patio area, with plans to build a conservatory. Ambleside Lodge DS0000022780.V315899.R01.S.doc Version 5.2 Page 19 This will be of benefit as a smoking area as presently there are no smoke free communal areas. Service users each have a single furnished bedroom. A service user said that he found his bedroom comfortable and adequately heated. Bedrooms seen were personalised and reasonably well decorated and homely. There are three toilets and two bathrooms, both with shower fittings. 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 a tour of the premises a number of health and safety issues were noted: • Fire doors were wedged open in hallways on the first and second floors • A garden shed containing household chemicals was unlocked • Window restrictors were missing from a recently replaced bathroom window The home manager locked the garden shed door and removed the door wedges during the inspection. (See requirements 3, 4 & 5). Ambleside Lodge DS0000022780.V315899.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. Reliance on a student workforce has led to a high turnover of staff that affects continuity of care and reduces the impact of the team training and development. Staffing levels are adequate to meet the needs of the service users and are reviewed regularly. Recruitment procedures do not offer sufficient protection in some cases. EVIDENCE: The home manager and registered provider work in the home as full time staff. Both are qualified and experienced in providing services for adults with mental health issues. There are currently five part-time support workers, who are all students, in addition to the registered providers. Daytime staffing levels consist of two members of staff (usually the registered providers). Two staff are on duty at night, one awake and one providing sleepover cover. A sleepover room with adequate storage facility is available. Ambleside Lodge DS0000022780.V315899.R01.S.doc Version 5.2 Page 21 The home manager said that student staff often resign when they complete their college or university education. High staff turnover does not provide service users with consistency and continuity of care. The appointment of permanent full-time staff is recommended. (See previous recommendation 2). However, on a day-to-day basis there is good continuity and the proprietors have close links with the associated health professionals involved in each persons care. A service user said, “The staff are very good here, very polite, no one tells you off, if they want you to do something they say please”. There is limited progress with obtaining N.V.Q training due to changes in staffing. The registered provider, who works in the home full time, is a qualified nurse and is studying an N.V.Q level 4 and the R.M.A (Registered Managers Award). Three of the five part-time staff are currently undertaking an N.V.Q at level 3 and one member of staff has just commenced the course. Training undertaken in 2005-2006 includes: • Equality and diversity (for the proprietors) • C.O.S.H.H • Infection control • Adult protection • Medication • Fire safety • Manual handling • Mental illness A team training and development plan is in place for 2006-2007. Training planned for 2006-2007 includes: • Food hygiene • N.V.Q at level 3 • C.O.S.H.H All staff should receive training in equal opportunities, including disability equality training, race equality and anti-racism training. (See recommendation 3). A member of staff with current First Aid training should be on duty at all times (See recommendation 4). Recruitment records examined indicate that application forms, references, enhanced C.R.B (Criminal Records Bureau) checks, photographs, completed health questionnaires, copies of training certificates and copies of passports are in place. Ambleside Lodge DS0000022780.V315899.R01.S.doc Version 5.2 Page 22 However, in two cases the home manager has made a photocopy of a C.R.B check obtained from a previous employer. Even though these checks are recent, C.R.B check certificates are not transferable, and the registered provider must obtain a new and satisfactory C.R.B check before any new employee begins working in the home. (See requirements 6 & 7). Copies of the GSCC Code of conduct are available in the office. The home manager has recently obtained and introduced ‘Skills for Care’ induction, as required in the previous inspection report. Ambleside Lodge DS0000022780.V315899.R01.S.doc Version 5.2 Page 23 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 adequate. 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 service users are able to contribute their ideas and views as part of the running of the home and quality assurance systems. Health and safety issues are promoted but must be improved in several key areas. 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 service users and know them well. Ambleside Lodge DS0000022780.V315899.R01.S.doc Version 5.2 Page 24 Both are nursing qualified and experienced in working with service users with mental illness. The registered manager has completed an NVQ at level 4 and an RMA. There is regular consultation with service users through house meetings and quality assurance questionnaires, the results of which are fed back to service users and published in the service users guide. Minutes of ‘house’ meetings provide evidence that service users are consulted about household issues and staffing arrangements. A service user confirmed that they found these meetings useful. The registered provider arranged for a care manager from another company to visit the home and conduct quality assurance inspections on the service provided at Ambleside Lodge. The reports of these inspections are available in the home. 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 extinguishers were professionally checked in August 2006. During the previous inspection it was noted that fire evacuation drills had not been held with the required frequency. Additional evacuation drills have been conducted as required. COSHH (substances hazardous to health) materials are not safely stored. (See requirement 5). Sharp knives are counted daily and stored securely in accordance with environmental risk assessments. The home manager said that small electrical appliances had been subject to an annual safety check in September 2006, but the certificate was not yet available. The mains electrical system had been safety tested in January 2005. The gas appliances had been safety tested in January 2006. The home manager said that the thermostatic control valves had been purchased but it is unclear whether all bathroom hot water outlets have been fitted with a temperature restricting valves. This is important as it prevents scalding injuries. Hot water temperatures are tested regularly and the results recorded. The recorded temperatures are within safe limits. (See requirement 8). Requirement are made in standard 24 in regard to fire doors being wedged open, which presents a fire risk, and windows opening without restriction, which presents a risks of falls and self injury. (See requirements 3 & 4). Ambleside Lodge DS0000022780.V315899.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 3 2 2 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 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 2 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Ambleside Lodge DS0000022780.V315899.R01.S.doc Version 5.2 Page 26 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 YA2 YA9 YA6 Regulation 14 Requirement The registered person must ensure that the care needs and risks relating to any new service user are adequately assessed and recorded by a competent person prior to admission to the home for a trial period. The registered person must ensure that individual care plans are discussed and agreed by service users and that they clearly identify any restrictions and conditions of the placement. The registered person must ensure that fire doors are not wedged open The registered person must ensure that window opening restrictors are fitted to all windows risk assessed as needing them and that these fittings are checked regularly. The registered person must ensure that substances hazardous to health are securely stored at all times. The registered persons must ensure that new staff are not employed before a satisfactory enhanced criminal records check DS0000022780.V315899.R01.S.doc Timescale for action 01/12/06 2. YA6 YA7 15 01/12/06 3. 4. YA24 YA42 YA24 YA42 23(4) 23 13 11/11/06 01/12/06 5. YA24 YA42 23 13 19 11/11/06 6. YA34 01/12/06 Ambleside Lodge Version 5.2 Page 27 7. YA34 19 8. YA42 23 13 has been obtained by the registered provider. The registered persons must ensure that two staff with CRB checks from a previous employer must be re-checked by the registered provider and these checks must include POVA First clearance. The registered persons must ensure that hot water outlets accessible to service users in bathrooms are fitted with valves that restrict hot water temperatures to within safe limits. 11/11/06 01/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA15 Good Practice Recommendations The registered person should consider ways in which visiting times can be reviewed to accommodate a service user who may wish to develop an intimate relationship with someone. The registered persons should recruit a sufficient number of full time staff. 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. 2. 3. 4. YA33 YA35 YA35 Ambleside Lodge DS0000022780.V315899.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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.V315899.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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