Inspection on 05/01/07 for Budge Lane (21)

This inspection was carried out on 5th January 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Budge Lane (21) 19/07/07

Budge Lane (21) 07/12/05

Budge Lane (21) 07/07/05

Budge Lane (21) 26/11/04

Budge Lane (21) 05/07/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Budge Lane (21) 21 Budge Lane Mitcham Surrey CR4 4AN Lead Inspector Ms Rin Saimbi Key Unannounced Inspection 5th January 2007 09:30 Budge Lane (21) DS0000007155.V325440.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 Budge Lane (21) DS0000007155.V325440.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. Budge Lane (21) DS0000007155.V325440.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Budge Lane (21) Address 21 Budge Lane Mitcham Surrey CR4 4AN 020 8640 5169 020 8640 5169 budgelane21@walsingham.com 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) Walsingham Mr Victor Stephen Green Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Budge Lane (21) DS0000007155.V325440.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7.12.05 Brief Description of the Service: 21 Budge Lane is a residential care home that was first registered in January 1997 to provide care for up to six adults with learning disabilities. The home specialises in providing a service to people who have a learning disability and who may also have a secondary physical disabilities. The accommodation compromises to six single bedrooms. There is a communal lounge towards the rear of the building overlooking the back garden, and a secondary lounge towards the front of the premises. Other facilities include a dining room, kitchen, laundry, garage, staff sleeping in room and staff office The home itself is located on a new estate, which has a mixture of housing association and private properties. The nearest shops are some 15 minutes walking distance away, it is not the most convenient place for some forms of public transport, however the home does have its own transport. The home is owned and run by Walsingham, which is a registered charity that has a Christian ethos. The current costs of the placement range from £1,214 to £1,379 dependent upon need. Placing authorities are advised to contact the home directly for more detailed information. Budge Lane (21) DS0000007155.V325440.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first inspection for the year 2006/07. It was an unannounced inspection that started at 9.30 am. The inspection took approximately five hours. The inspection took the form of discussions with the majority of service users, staff on duty and observations of staff interaction with service users. In addition, there was a tour of the building and looking through documentation, which related to service users and staff to make sure that they were relevant, accurate and up to date. The manager was not available on the day of inspection, however the deputy manager was. The inspector would like to thank the staff and service users for their time and co-operation during the inspection process. In particular, the inspector wishes to thank the service users whose plans had to be re-arranged due to inspection taking place. What the service does well: Service users when asked about the level of care that they were receiving were all positive. One service user stated ‘they look after you, I like it here’. Service users were observed to be interpreted into the local community, four example visiting the local shops to buy what they wanted for lunch; Family and friends are encouraged to visit the home, or to take service users out. Risk assessments were working documents; they covered environmental factors and those specific to individuals. They are reviewed on an annual basis at least, or sooner should it be necessary. All staff receive supervision at the required level. A written document is kept of the meeting and signed by the both parties. Supervision is planned well in advance and was in evidence on the staffing rota. Walsingham are committed to ensuring that their workforce has a solid foundation during their induction period; and that staff then undertake regular training in order to improve their knowledge and skills. This was evident as Budge Lane (21) DS0000007155.V325440.R01.S.doc Version 5.2 Page 6 staff were all able to communicate effectively with service users even though they had very different communication patterns. What has improved since the last inspection? What they could do better: It is disappointing to note that a number of requirements have been outstanding for some considerable. In particular relating to the physical environment of the home. The kitchen is in need of some attention as doors are coming off hinges, units are chipped and drawers will not close properly. This was first identified in February 2004 and remains outstanding. In addition, the kitchen was not clean. The dining room table and chairs needs to be replaced, as the surface on the dining table is tacky because of the varnish, it is also not stable; chairs can be pulled apart. This is outstanding since October 2005. The condition of the carpet must also be reviewed; this is outstanding since October 2005. The Commission require that an action plan be drawn up which gives a clear indication of when the work will be undertaken. With regard to record keeping, service users files were in a chaotic state. Whilst accepting that there is a transition phase between Individual Planning and Person Centred Planning, records were still not in good order. Information could not be located, was misfiled or out of date. This was particularly of concern with regard to the health needs of service users. A requirement has Budge Lane (21) DS0000007155.V325440.R01.S.doc Version 5.2 Page 7 therefore been made that files must be maintained in accordance with the Data Protection Act. Staff must also be made aware of their own internal policies and procedures in particular with regard to the receipt of gifts from service users. 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. Budge Lane (21) DS0000007155.V325440.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Budge Lane (21) DS0000007155.V325440.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has gathered information from a variety of sources and then completed their own thorough assessment for all service users. For potential new service users this process would be completed in conjunction with the service users themselves and their family, friends and advocates. The aim would therefore be that service users would not just be fitted into a vacancy; but that the service users themselves would make an active choice about the accommodation that they wanted to live in. To aid in this process, a new service users guide has been written. EVIDENCE: Budge Lane (21) DS0000007155.V325440.R01.S.doc Version 5.2 Page 10 The home has been open since 1997; all service users who arrived at that time came with an assessment. These documents were checked at the previous inspection and were of variable quality. The home has subsequently devised a care assessment for each of its service users. This document contained general information, which was gathered from the original assessment plan, and from the homes own assessment process. Walsingham have their own ‘assessment of needs’ for all potential service users. This document was extensive and comprehensive with areas for likes, dislikes, significant friends and family, sexuality and level of disability. The home has recently developed a new service users guide, which comprises of photographs, drawings and some written text, which is in plain English. The document is specific to the home in that it includes photographs of the local area, amenities and the home itself. It also includes a photograph and a brief pen picture of the service users that are currently living at 21, Budge Lane. A new contract has also been devised which focuses on the service users and what they can expect from the home. The home is able to meet the needs of the service users either by the skills and experience of the staff team, or by the use of outside professional agencies. A physiotherapist is currently involved with service users and visit on a regular basis; a psychologist and district nurse visit as and when is required. All service users within the home are able to communicate their needs either verbally or through gestures. The staff team all have the necessary skills and understanding of the varying forms of communication so that they can meet the needs of service users. From observations it was evident that this was the case. Budge Lane (21) DS0000007155.V325440.R01.S.doc Version 5.2 Page 11 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): 6,7,8 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are given some opportunities to make choices regarding daily activities; what they eat and when, through to senior staff appointments. There was no recent evidence that service users have been given opportunities to achieve an independent lifestyle. Choices may have been limited and service users may not have as full control of their lives as possible. EVIDENCE: The home is in the process of transition with regards to its documentation for service users. All service users did have a document entitled ‘my goals’ which was reviewed annually, written in plain English and in a format accessible to Budge Lane (21) DS0000007155.V325440.R01.S.doc Version 5.2 Page 12 service users. However, the home is now in the process of introducing Person Centred Planning (PCP). This was started with some service users but has been stopped whilst Walsingham develop the policies to proceed appropriately. The home could not provide any evidence that service users are currently being consulted about their needs, wishes, aims and goals. A requirement has therefore been made that service users must have an internal six-monthly review to look at there wishes, and that this information must be recorded. Previous inspections had identified that service users had not had annual reviews with Social Services. The home has improved in this area, with all reviews with Social Services having taken place within the last two years. A number of reviews for service users were cancelled over the summer period, as the nominated care manager was leaving the department. There was a copy of a letter written by an advocate requesting a further date. A requirement therefore remains that the home must provide written evidence that they have approached the appropriate Social Services department requesting reviews that are outstanding. The purpose and function of daily recording is inconsistent within the home. The inspector was informed that only exceptional events were to be recorded. In actual fact the evidence was that some entries stated ‘that service user relaxed at home and watched T.V.’ and that there were then no entries for four days. As there is no evidence of the activities undertaken by individual service users within the home, a requirement has been made that the daily recording must be completed Risk assessments were checked; there was evidence of environmental assessments and those specific to service users. All documentation was appropriate and there was evidence that it was reviewed on a regular basis, that it to say, at least annually. Only one of the service users attends a day centre, the inspector was informed that the other service users had all chosen not to attend. One of the service users volunteers at the local library once a week, a member of staff supports him in this. One of the service users attends regular meetings entitled ‘ Walsingham against Cotton Wool.’ Two of the homes service users have been on interview panels for staff for many years. They were given training in this area and undertook mock interviews. Subsequently, one of the service users has joined a regional Budge Lane (21) DS0000007155.V325440.R01.S.doc Version 5.2 Page 13 interview panel which interviews managers and senior personal for posts. The questions asked were gathered from all the homes in the area. ‘Advocacy Partners’ are involved with one of the service users at the home. Another of the service users has contact with an independent family, who have become friends, on a regular basis. Service users are able to come and go as they wish, although this is something that they often do not do. One service user was observed taking himself to a sister home, with staff just having to inform the sister home that he was on his way. Budge Lane (21) DS0000007155.V325440.R01.S.doc Version 5.2 Page 14 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 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users within the home live ordinary and meaningful lives, and participate and contribute to the communities in which they live. There is an emphasis within the home of developing and maintaining personal and family relationships. This allows service users to feel that they belong, and that there is someone external to the organisation that can consider their welfare. EVIDENCE: Budge Lane (21) DS0000007155.V325440.R01.S.doc Version 5.2 Page 15 Service users are encouraged to maintain friendships and family contact. Three of the service users do not have any family contact. The home has a representative from ‘Advocacy Partners’ involved with one of the service users. Another has an advocate’s family involved whom he visits on a regular basis. Where there is contact with family, friends or advocates the home will try to maintain this. All the service users have a birthday party, if they chose; family are invited into the home at formal events such as Christmas and are welcome at other times. Three of the service users currently participate in spiritual activities and are encouraged to attend specific churches of their choice. One particular service user is keen on jazz music. The home is able to access live jazz music in the community, which includes at pubs and music venues. The service user has in previous years attended a jazz holiday. This year he was unfortunately unwell and missed out. All other service users have been holiday over the summer period, two of the service users chose to go together to Spain; there were two other trips by service users to Spain. Service users are encouraged to participate in community activities by the provision of a house car. In addition all service users have their own bus pass. One service user has his own car, which is driven by staff; another service user has their own scooter. Service users are able to choose when they wish to have their meals and what they have. One service user was observed to go out and chose his own food at lunchtime, staff asked others what they wanted and assisted in the preparation if required. Service users were observed helping themselves to drinks users. Budge Lane (21) DS0000007155.V325440.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. In general it seems that the staff within the home are able to provide personal care which ensures privacy and dignity at all times. There is an awareness and understanding that service users have the right to expect the same healthcare as others in the community, however, there appears to be omissions in the healthcare provided. The consequences of this may be that service users health needs are not being fully met. EVIDENCE: Service users are supported to manage their own healthcare needs, some are able to take themselves to their own GP and have a private consultation, and others need support to do this. Budge Lane (21) DS0000007155.V325440.R01.S.doc Version 5.2 Page 17 The home does maintain a record of health appointments. The inspector checked documentation relating to two service users. In general, the records appeared up to date, although there were some omissions. In both files, service users had not seen the dentist since May 2005. Nor was there any evidence of an annual review being held by the G.P. This had been an outstanding requirement since August 2005. This is of concern to the Commission and the home must act for with to ensure that service users health needs are being appropriately met. Service users within the home receive sensitive personal support, which maintains their privacy and dignity. Service users are able to choose their own clothes and toiletries; personal support in provided in private; discussions with staff confirmed that they are aware of issues surrounding previous and dignity. No service users within the home are able to self-administered medication. The medication is stored in a locked metal cabinet, which is sited in a locked cupboard. Medication arrives in the home in Dossette packs on a monthly basis. ‘Boots the Chemist’ audits the home on a regular basis, the last occasion being on the 30.11.06. The Medication Administration Records (MAR) records were checked. There were no errors found. A previous requirement that MAR charts must be completed is therefore withdrawn. Budge Lane (21) DS0000007155.V325440.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. In general it appears that service users at the home feel listened to and confident that their views will be taken seriously. This acts as an added safeguard to ensure that service users safety is paramount and that they are protected as far as possible for risk as vulnerable adults. EVIDENCE: The home has a general complaints policy which was dated August 2004, it contains information about the process, how long it should take and what to do if you are not satisfied with the response. The home does have a complaints log, which had six entries in the last year. The majority of complaints relate to the environment of the home, some of the complaints have not been actioned, for example the condition of the kitchen. The home has robust polices and procedures in place to make sure that service users are kept safe. There is Walsingham’s own vulnerable adults policy and in addition they have a copy of Sutton’s own procedural guidelines. The home has a whistle blowing policy. Budge Lane (21) DS0000007155.V325440.R01.S.doc Version 5.2 Page 19 Within the new service users guide developed by the home, there is a userfriendly format for making a complaint or a compliment; this format has been specifically developed for the service users who currently live within the home. Budge Lane (21) DS0000007155.V325440.R01.S.doc Version 5.2 Page 20 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): 24,25,26,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides service users with specialist aids and adaptations required for daily living so that they can be as independent as possible. The home is not being maintained well and there are some areas that are shabby and in need of urgent renewal. The home is not clean and hygienic so service users are not benefiting from a homely environment. There is a respect for service users privacy, enabling them to come and go as they wish, to receive guests in private and to have a key to their own bedrooms EVIDENCE: Budge Lane (21) DS0000007155.V325440.R01.S.doc Version 5.2 Page 21 The home’s accommodation is all on the ground floor and has been made wheelchair accessible by allowing sufficient width in all the doorways. The home is in keeping with its environment. Some of the furniture and fittings of the home are generally of good quality and domestic in style. However, the dining room table and chairs is in urgent need of renewal. The table is not stable, the varnish is tacky and a chair can be pulled apart. A requirement was made in August 2005 that the dining room table must be renewed and this is still outstanding. This requirement needs to be actioned for with. All service users have their own bedrooms, which are personalised according to their interests and tastes. Service users have their own keys to their bedrooms which some of them use, and in addition a lockable space in their bedrooms. The condition of the carpet needs to be reviewed throughout the building, in particular the lounge and bedrooms where it is stained. This is also an outstanding requirement from previous inspections. The small lounge has wallpaper peeling off which must be made good or replaced. The home has sufficient outdoor space, including a grassed area and patio. These areas are accessible for wheelchair users. The kitchen is domestic in style and has partly been adapted for wheelchair users, with lowered work surfaces. The kitchen is however in need of refurbishment as some the kitchen doors are working themselves loose and work surfaces are also chipped. A requirement was first made in February 2004 regarding the kitchen and still remains outstanding. The Commission have been informed that the work will be started in February. The kitchen was also dirty, and therefore a further requirement has been made in this regard. A separate sleeping-in room is provided for staff, with some storage for personal belongings Budge Lane (21) DS0000007155.V325440.R01.S.doc Version 5.2 Page 22 The home has some moving and handling equipment, this includes overheadtracking hoists observed in the bedrooms, and a shower trolley. There were adaptations in the bathrooms and toilets, which included grab rails. Electrical sockets and light switches were in accessible places for wheelchairs users and there was evidence of a call alarm system throughout the building. Budge Lane (21) DS0000007155.V325440.R01.S.doc Version 5.2 Page 23 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): 31,32,33,35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is an emphasis at the initial stages on induction and that core skills are acquired so that service users feel that they are understood and listened to. The home needs to continue this emphasis in relation to NVQ’s thereby ensuring that staff continue to be effective. In addition, the home needs to remind its staff of its own policies and procedures regarding gifts. EVIDENCE: All new staff at the home receives a six-week induction, followed by core skills training, which covers areas such as health and safety, food hygiene and manual handling. Walsingham emphasis the importance of the training for their staff group. Records checked indicated that staff have all had the required level of training, Budge Lane (21) DS0000007155.V325440.R01.S.doc Version 5.2 Page 24 that is to say at least five days per year. This training has included two days training on diversity issues a few weeks ago. At the last inspection, the home was on target to meet the 50 deadline of care staff having completed their NVQ qualifications. However, the home are no longer on target to meet this deadline. Only two members of staff have completed their NVQ’s and one is in the process. A requirement has therefore been made that the home get back on track to meet the revised deadline. Currently within the home there are nine full time members of staff, plus one who works 30 hours per week and another who works 20. By the end of January however, there will be three full-time vacancies within the home. The home expects that on any one shift during the day, that there will be three members of staff on duty. The inspector sampled the duty rota at random, including over the New Year period. The rota confirmed the number of staff on duty, with any vacancies being covered by agency staff. At night the home has two members of staff on duty, one on waking night and the other on sleeping in. Within the service users group there are four men and two women all of whom are white/European. Within the staff group there are seven women and two men from a culturally diverse groups. Whilst acknowledging the male/female balance could be better, it is nonetheless positive that the home does at least have two male members of staff Staff records for supervision were viewed for three members of staff; notes were available for these meetings, which were signed by both parties. Discussions with members of staff confirmed the regularity of supervision as being approximately monthly. Recruitment files are not kept within the home, but centrally. This is with the agreement of the Commission. Recruitment files are instead checked by a senior officer from the Commission on a regular basis. The home must make clear to its entire staff their own internal policy and procedures regarding the receipt of gifts from service users. This issue arose as one service user has bought many gifts for staff, including some with a high monetary value. A requirement has been made in this regard. Budge Lane (21) DS0000007155.V325440.R01.S.doc Version 5.2 Page 25 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): 37,40, 41 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Walsingham have policies and procedures in place to ensure the welfare and safety of staff and service users. Greater emphasis needs to put on the homes records to ensure that they are up to date and in good order to assist the welfare and care of service users within the home. EVIDENCE: Budge Lane (21) DS0000007155.V325440.R01.S.doc Version 5.2 Page 26 The registered manager, Mr V. Green, has ten years experience in the field of learning disabilities; he has been a manager for six of those years. He is in the process of completing his NVQ Level 4, which he hopes to complete by July 2007. Walsingham takes seriously its responsibilities to ensure the safety and welfare of service users and staff. The inspector checked various documentation in relation to this. Gas certificate was dated the 1.8.06; Legionella on the 11.8.06; fire equipment was checked on the 10.12.06 and the last fire alarm testes were on the 4.1.07; PAT was completed on the 7.9.06 and the employers insurance liability expires on the 31.3.06 It was noted that the last fire drill had taken place on the 15.11.05. A requirement has therefore been made that fire drills are in held within the required timescale set out by the Fire Precautions Act 1971. A requirement was also made that the shower screen leaning against the bath must be removed for with. With regard to record keeping, service users files were in a chaotic state. Whilst accepting that there is a transition phase between Individual Planning and PCP, records were still not in good order. Information could not be located, was misfiled or out of date. A requirement has therefore been made that files must be maintained in accordance with the Data Protection Act. Budge Lane (21) DS0000007155.V325440.R01.S.doc Version 5.2 Page 27 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 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 X 28 3 29 3 30 2 STAFFING Standard No Score 31 2 32 2 33 3 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 3 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 3 X 3 X X 3 2 2 X Budge Lane (21) DS0000007155.V325440.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? Yes 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 2 3 Standard Regulation 15(1) 14(2) a & b 15(2)(b) Requirement Daily recordings must record the activities undertaken by service users The home must review its individual plan with service users on a six-monthly basis. The home must review the needs of service users on a formal basis. If this has not been possible, to provide evidence that they have contacted the appropriate authorities Outstanding requirement from previous inspection 7.12.05 The home must ensure that service users have access to health facilities Outstanding requirement from previous inspection 7.8.05 Environment a) the condition of the kitchen must be made good. Outstanding requirement from previous inspection 1.2.04 Budge Lane (21) DS0000007155.V325440.R01.S.doc Version 5.2 Page 29 Timescale for action 05/02/07 05/02/07 05/03/07 4 12(1)(a) and 13(1)(b) 05/01/07 5 23(2) 05/03/07 b) The dining table and chairs must be replaced Outstanding requirement from previous inspection 7.10.05 c) The condition of the carpet must be reviewed Outstanding requirement from previous inspection 7.12.05 d) The condition of the wallpaper in the small lounge must be made good. The kitchen must be cleaned 6 7 8 23(2)(d) 05/01/07 05/01/07 05/02/07 9 10 11 18(1)(c)(i) Staff must be made aware of the homes policy and procedures in relation to accepting gifts 18(1)(a) The home must review the numbers of staff completing NVQ’s and ensure that the number is increased 17(3)(a) Records relating to service users must be in order, up to date and maintained and constructed appropriately 23(2)(c) The shower screen which is currently leaning up against the bath must be removed 23(4)(a) Fire drills must be undertaken in accordance with required levels 05/02/07 05/01/07 05/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Budge Lane (21) DS0000007155.V325440.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Budge Lane (21) DS0000007155.V325440.R01.S.doc Version 5.2 Page 31 - 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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