Inspection on 30/06/06 for Camellia Lodge

This inspection was carried out on 30th June 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Camellia Lodge 31/05/07

Camellia Lodge 06/01/06

Camellia Lodge 27/06/05

Camellia Lodge 01/03/05

Camellia Lodge 13/09/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Camellia Lodge 134 Holt Road Horsford Norwich Norfolk NR10 3DW Lead Inspector Mrs Dorothy Binns Unannounced Inspection 30th June 2006 10:00 Camellia Lodge DS0000027558.V303214.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 Camellia Lodge DS0000027558.V303214.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. Camellia Lodge DS0000027558.V303214.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Camellia Lodge Address 134 Holt Road Horsford Norwich Norfolk NR10 3DW 01603 890733 NO FAX # 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) www.caremanagementgroup.com Care Management Group Limited Mrs Deborah Jane Johnson Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Camellia Lodge DS0000027558.V303214.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th January 2006 Brief Description of the Service: Camellia Lodge is a care home providing personal care and accommodation for up to 4 younger adults with a learning disability. The service users may also have a physical disability. Care Management Group Limited, whose registered office is located in London, owns Camellia Lodge and four other small homes in the Norwich area. There is a lot of contact between all of the homes. This home is located within the village of Horsford and not far, though a bus ride away, from the city of Norwich. Local amenities, shops and pubs are also close by. The home consists of an adapted bungalow and provides a domestic setting for the service users, each of whom has their own single bedroom. One of the bedrooms has an ensuite shower. A lounge and dining room comprise the communal space and there is an accessible rear garden and limited parking to the front of the home. Camellia Lodge DS0000027558.V303214.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was a key unannounced inspection of the home lasting four and half hours. During the visit the progress of the home was discussed with the registered manager and with the team manager of the home. Records and policies were examined and staff were spoken to. The service users were observed as they spent their time in the home and a tour was made of the building. Only the key standards were inspected on this occasion. The report also comments on information received by the commission since the last inspection. Surveys of the service users views were sent out by the commission but were not returned as the service users are unable to comment. What the service does well: What has improved since the last inspection? The organisation and management have worked hard to make changes in how service users finances are looked after. Service users now have their own bank accounts and the receipt of their benefits and how they are banked and used with staff assistance is now clear and transparent. This gives much more protection to the service users. The recruitment process is much more rigorous with new staff having to have all the checks before they are employed. Training has recently been increased providing all staff with basic training. There is still work to be done but this is an improvement. Camellia Lodge DS0000027558.V303214.R01.S.doc Version 5.2 Page 6 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. Camellia Lodge DS0000027558.V303214.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 Camellia Lodge DS0000027558.V303214.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The quality of this outcome area is good. Service users needs are comprehensively assessed. EVIDENCE: Two files were examined and very full assessments were in place covering a range of topics from health to behaviour, communication to skills. In one file of a new service user full details were provided by the social work and hospital authorities on the health and presentation of the service user. The information included how the service user may be managed with procedures that would be helpful to staff. On top of this information, the homes own care document was completed. This gave plenty of information to management to help them decide whether they could cater for the person’s needs. Camellia Lodge DS0000027558.V303214.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 The quality of this outcome area is good. Service users have their assessed and changing needs reflected in the care plan with risk assessments to help them to be safe. They are enabled to make as many day to day decisions as they can and with help have good access to their money. EVIDENCE: Two care plans were examined. They are linked with the assessments and provide a lot of information about how to assist the service users. Particular aspects such as managing seizures were spelt out for staff and there were procedures for coping with specific behaviours. The care plans showed the use of the community support team in the two service users affected and the attendance at skills centres. However there was not much about the social care needs of the service users and these should be included. Staff write full reports every day commenting on the general well being of each service user and what their day has involved. Reviews had been held recently. Staff said that service users are not able to make their own decisions except in a limited way. Staff learn from signs, sounds and general body language what service users like or what makes them unhappy and try to see that they have the choices they want. The philosophy of the home and the attitude conveyed by staff is that the service users are at the heart of decision making though Camellia Lodge DS0000027558.V303214.R01.S.doc Version 5.2 Page 10 staff were unhappy that service users were confined to the home three days a week and felt they would much prefer to go out for a while. However staffing prevented this. In terms of service users being in charge of their own money, a requirement was made at the last inspection to have a more transparent system for looking after service users accounts and the Commission has heard from the head office of this company that they were working hard to deal with this. On this visit much progress could be seen with all service users having their own bank accounts into which their benefits were paid or were about to be paid directly. The home kept a record of the amounts to be paid in so that they could check the bank statements on the service users behalf. Only certain staff at the regional office can be signatories on these accounts and they draw money so that the service users have something to spend. This comes to the staff in the home who keep a record of anything spent. These records were checked against the cash held and found correct. This is a much more transparent system where the service users’ money can be traced and you can see what is happening to it. This is a vast improvement and gives far greater protection to the service users. Service users are very dependent and vulnerable and cannot go out on their own. The level of independence is small. There are risk assessments in place though to try to maximise their independence. Risk assessments were seen for bathing, travelling, road safety and responding to a fire alarm. All situations where there might be risk are looked at and actions laid down for staff to follow. Camellia Lodge DS0000027558.V303214.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 The quality of this outcome area is poor. Although there are some good aspects to these standards in terms of the staff’s promotion of the rights of the service users and the provision of food and the flexibility of routines, the inability of the staff to ensure that the service users have access to community facilities and can fulfil their social care needs gives concern to the Commission. EVIDENCE: Service users are not able to work or attend voluntary schemes because of their disability. They all attend two days at skills centres outside the home which gives them some extra stimulation. Otherwise they are dependent on staff to help them to access facilities in the community. Although there was some evidence that service users did go out in to the local community, for instance one person goes riding regularly and on occasions staff can take service users out to pubs and fetes, on the whole there is currently little opportunity to go out except on those days when they go to their skills centres or the two days when two of the service users are given extra attention by the community support team from social services. The Camellia Lodge DS0000027558.V303214.R01.S.doc Version 5.2 Page 12 activities chart showed that from Mondays to Thursdays, service users are out at centres though on Tuesdays three of the service users are at home, and on Thursdays two are at home. On Fridays, Saturdays and Sundays, all four service users are at home. Because of the combination of the needs of the service users, the number of staff on duty (the rota showing only ever two on duty) and the lack of transport, staff cannot leave the premises with the service users on those days they are at home. With only two staff on duty, it is not possible for them to manage the two service users who use wheelchairs when they go outside, and keep a close eye on the two service users who can walk independently. One service user is reported by staff to need two staff with her outside. Because of the needs of the service users, it is not possible to have one staff go out with two service users and leave one at home with the remaining two. A car is only available to the home on Mondays and Wednesdays when they use it to transport the service users to their skill centres and take them and others out from the centre (the staff staying with the service users at the centre). This is a poor state of affairs and the home is not meeting the social care needs of the service users. They are either admitting service users who they are unable to cater for or failing to provide sufficient staffing to cater for the service users needs. A requirement has been made to remedy this situation. In terms of family contact, there was reference in the files to the extent of family contact and staff informed the inspector of the details. One service user goes to his family one day a month and two others have occasional visits from their relatives. Staff said they would encourage family contact and make relatives welcome but sometimes there is little contact. Service users are quite dependent on staff and have little speech but in terms of their routines the staff have a good understanding of the service users and know who likes to sleep late, who likes to go to bed early. Staff said two service users can take themselves to bed so choose their own times. Service users also have a chance to spend time in their room by themselves and listen to their own music or be quiet. This was clear during the visit when one service user in particular spent time in her room. One service user when sitting outside indicated that she was unhappy so staff led her indoors. Staff are always with the service users so are sensitive to the sounds and other pointers service users give to indicate their views. Where staff have to take the initiative is to help the service users with their outings as they are unsafe on their own and on such things as helping them to open their mail and telling them what is being said. They have to help them choose their clothes and one staff described how she did this. Service users may also not be able to articulate how their hair should be so staff take the responsibility for seeing that they look their best. Overall service users’ rights are respected and staff were mindful of the need to allow the service users as much responsibility as possible. Camellia Lodge DS0000027558.V303214.R01.S.doc Version 5.2 Page 13 The menus were seen showing a three weekly rotating menu which looked appetising and varied. Staff said there were no special diets. Lunches are now more varied and salad was being prepared for lunch. Staff said they always had fresh fruit every day and fresh ingredients are bought. Staff felt the budget for food was good and the service users were well provided for including having snacks in the evening and sweets and drinks. Breakfast is a moveable feast depending on when the service users get up but other meals are usually taken together. Camellia Lodge DS0000027558.V303214.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 The quality of this outcome area is good. Service users are supported in a way that protects their dignity and privacy and their health needs are monitored well. Service users cannot look after their own medication but the home’s policies and records confirm that they are protected and staff administer the medicines safely. EVIDENCE: Staff said that all service users need some personal support and are assisted in the bath and in their personal care. They are assisted in private and one service user has their own ensuite shower facility. An occupational therapist has been consulted on the positioning of grab rails to help service users with their mobility. Staff reported flexible routines with getting up and bedtimes decided by the service users. They do need guidance from staff on many matters as three are without speech and they are not able to make many decisions themselves. To provide consistency, there are only five in the staff team plus the team manager. Because of recent staff changes, the key worker system has lapsed though the intention is to re introduce this again. However staff seemed to know the service users well and have a good understanding of their needs and wishes. There was plenty of evidence in the records of contacts with health professionals. Regular visits for blood tests, chiropodists and opticians were Camellia Lodge DS0000027558.V303214.R01.S.doc Version 5.2 Page 15 recorded as well as contact with the GP. One service user bruises very easily because of her condition and a body chart is regularly completed to monitor her. Those with epilepsy are also monitored with seizure charts. There was also mention of liaison with psychiatrists and social workers. Staff also report daily on the health and well being of the service users and the evidence was that health was properly monitored and action taken when necessary and on a regular basis. Medication systems were checked. Medicines are stored in a locked cupboard and staff administer them correctly, the daily administration record being satisfactorily completed. A monitored dosage system is used, prepacked by the pharmacist and safer for staff. However the Commission was informed earlier in the year that a mistake in medication had been made by an agency staff. This was dealt with by the manager informing the agency and ensuring that only trained staff in medication were allocated to the home or that agency staff were only on duty with an experienced member of staff. An agency staff on duty during this site visit confirmed she had been trained in medication and was quite confident of her role. The evidence showed that this matter had been dealt with and there had been no further mishaps. There are protocols in place for the provision of tablets on an “as required” basis which is good practice. Three of the service users also have epilepsy and require immediate attention if they have a seizure. Most of the staff have been trained in providing rectal diazepam (staff files seen) and the team manager said that the rota is arranged so that there is always someone on duty who can administer that medication. Camellia Lodge DS0000027558.V303214.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The quality of this outcome area is good. Service users are limited in their communication but can rely on staff to try to interpret their views. They are protected from abuse by the home’s policies and staff training. EVIDENCE: The complaints procedure is in the service users guide and it is illustrated making it easier to understand. The complaints record was in place but none had been recorded. No complaints have reached the Commission. Abuse policies are in place including a whistle blowing procedure. The procedures include referring to the adult protection unit. The documentation of a recent referral (which the Commission was aware of) was checked. There was reference in the service users care plan and a special chart for a medical condition was in place but there was no reference in the daily notes to the referral nor was there a change to the care plan after the investigation (which found a medical condition to be the cause). A separate action plan was written and a staff meeting was held by the manager following the investigation to inform staff of the changes. So clearly action was taken but the documentation was not coordinated. This should be absolutely clear to ensure all staff including agency staff are aware of the care required. However it was clear that any suspicion of abuse is taken seriously and the matter investigated. Camellia Lodge DS0000027558.V303214.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The quality of this outcome area is adequate. Most of the building is bright and attractive for the service users and the garden is slightly improved. It is in the detail that the home lets itself down and does not act quickly enough to make repairs. The lack of a fence is considered dangerous for the service users and curtails their independence. EVIDENCE: The building is looking bright and attractive with new carpets and redecoration following the building of an extension providing an extra bedroom and ensuite shower room. Personal belongings were in evidence making bedrooms individual, and covered radiators are installed making it safe for the service users. One of the service user’s chest of drawers was broken and needed to be replaced. It had been a requirement of the last inspection that the garden be improved and improvements were looked for. The garden had been grassed over following the building work and although not landscaped was usable by the service users. However the side fence had not been replaced since the building work was carried out. This meant it was impossible to leave the service users outside alone as there was free access to the front and the main road. This Camellia Lodge DS0000027558.V303214.R01.S.doc Version 5.2 Page 18 made the area unsafe for the service users. A requirement has been made to address this. The laundry is done in the kitchen with the washing machine in there. This was leaking and the handle had come off. Staff said they had asked for a replacement. Staff were aware of the need for controlling infection when doing laundry in the kitchen and gave a good account of the procedures. The house was clean and hygienic. Camellia Lodge DS0000027558.V303214.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 and 36 The quality of this outcome area is adequate. The commitment of the staff, the procedures for recruitment, and the induction training are good and mean that the service users are protected and supported. The staff coverage is basic and does not cover all the high activity periods or cater for all the needs of the service users. EVIDENCE: There are some long serving staff at this home who know the service users well. When talking to staff it is clear that they give full acknowledgement to the principles of dignity and independence in the care they offer to service users. They are aware of their specialist needs. They are also aware of what activities help the service users, what calms them, what upsets them. They have developed ways of understanding the service users, who have little language, by visual and aural expressions. More experienced staff help newer staff by working alongside them. Training certificates on staff files showed a lot of recent training on medication, health and safety and adult protection and it was clear that the organisation has made an effort this year to increase the training of staff. One staff is already qualified to NVQ3 level, another is doing it and another is registered but not started. This is not yet meeting the standard of 50 of staff trained but it is on its way. With such a challenging group of service users, it is vital that staff are adequately trained and the emphasis given to training this year needs to continue. Camellia Lodge DS0000027558.V303214.R01.S.doc Version 5.2 Page 20 The home extended its accommodation this year to enable four service users to be accommodated. Part of that agreement to registration was that the home would have adequate staffing to cater for the increase from three. The home is now putting two staff on the rota at all times during the day and with one staff on duty at night. What was found on this visit was that while the staffing is adequate while service users are at home or when two or three attend other centres during the day, it is not adequate when service users need to go out. On three days a week, Fridays, Saturdays and Sundays, all four service users are at home and dependent on staff. With only two staff on duty, service users are unable to leave the premises as more than two staff are needed. (One service user needs two staff outside, two need wheelchairs and all need constant attention) If one staff takes a person out, it can leave the other staff with three very dependent service users to look after and would not be safe. The service users are therefore unable to leave the house for three days. The Home also does not have access to a vehicle during this time. This is not effective staffing and not meeting the needs of the service users. Staffing is not varied enough to cater for the areas of high and low activity. Staff are keeping the service users safe but have no opportunity to provide a change of environment or adequate stimulation. The staffing must be increased on the three relevant days. In addition the home must look at its admission policy and ensure that it is only admitting service users who can be catered for and whose presence is not jeopardising the needs of the other service users. Requirements have been made. It had been a requirement of the last inspection that recruitment procedures were tightened. Two recruitment files were examined and found to contain all the required references and checks to make a safe system of recruitment. Interview notes, identity documents and a declaration of health were also included. Staff did not start work until the required checks had been made. Staff are issued with job descriptions and the code of practice of the General Social Care Council. This is good practice and the requirement met. Two files were seen for the newest staff and they both contained induction training. Staff files showed what training staff had received. A training needs analysis of the whole staff group was not in place and this is recommended to ensure that all staff are receiving appropriate training for the client group. Staff files showed that the one to one supervision of staff has been taking place but has not been as frequent as it might be. A contributory factor may be that with a fourth service user now in place, the team manager has no time to perform this duty. Staff work closely together so are being overseen but they should have the opportunity to discuss their work with their manager. Camellia Lodge DS0000027558.V303214.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 The quality of this outcome area is good. Service users are benefiting from committed staff and are protected in areas relating to health and safety. There are processes for evaluating the service. EVIDENCE: The registered manager has only been in post a short time and has taken her responsibilities seriously. She oversees all five of the small homes in this area. The new structure of the organisation has provided a team manager in each home who sees to day to day responsibilities and this seems to have eased the burden of managing all five homes. The manager is also supported by a structure of management from head office who decide on policy. However the manager is leaving in a months time and the organisation will be looking for a replacement. A full quality assurance system was in place enabling the home to check whether what it is providing is of the quality it wants. A set of aims was seen and whether they were met, a premises audit was in place and the intention is Camellia Lodge DS0000027558.V303214.R01.S.doc Version 5.2 Page 22 to produce an action plan for improvement. This has not yet been produced but the structure is in place to have a full quality audit. A wide range of policies dealing with the health and safety of staff and service users were in place giving protection to staff and service users. Staff files showed that basic training in all aspects of safety were provided including fire, first aid, health and safety and moving and handling. Certificates were seen for checking equipment and the fire system and there has been a recent fire drill. The accident record was kept and could be cross referenced to the care record of the service user showing documentation was correct. A health and safety risk was in place for the building. Camellia Lodge DS0000027558.V303214.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 2 33 2 34 3 35 2 36 2 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 1 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Camellia Lodge DS0000027558.V303214.R01.S.doc Version 5.2 Page 24 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 23(2)(b) Requirement The registered person is required to ensure that the garden, pathways and patio are safe and accessible for the service users to use. In this instance the provision of a fence is essential. Previous timescale of 31/03/06 was partially dealt with. Timescale for action 31/08/06 2. YA13 YA33 18 3. YA30 16 4 YA36 18(2) The registered person must 30/09/06 ensure that at all times there are enough suitably qualified staff working in the home to cater for the health and welfare of the service users. The registered person must 31/08/06 provide adequate facilities and arrange the regular laundering of linen and clothing. In this instance the provision of a suitable washing machine is required. The registered person shall 31/08/06 ensure that staff are adequately supervised. Camellia Lodge DS0000027558.V303214.R01.S.doc Version 5.2 Page 25 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 YA32 Good Practice Recommendations It is recommended that a training plan is devised showing what training staff have received and what they are expected to achieve in the coming 12 month period. It is recommended that a new chest of drawers is purchased for one of the service users. 2. YA24 Camellia Lodge DS0000027558.V303214.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Camellia Lodge DS0000027558.V303214.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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