Inspection on 21/02/06 for Clarence Park Lodge

This inspection was carried out on 21st February 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Clarence Park Lodge 07/01/09

Clarence Park Lodge 11/01/07

Clarence Park Lodge 07/10/05

Clarence Park Lodge 20/12/04

Clarence Park Lodge 14/06/04

Clarence Park Lodge 10/03/04

Similar services:

Clouds House

Closereach

Westcliffe House

Hilldales

Longreach

Chandos House

Cherry Orchards Camphill Community Ltd

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

CARE HOME ADULTS 18-65 Clarence Park Lodge 15 Clarence Road East Weston Super Mare North Somerset BS23 4BP Lead Inspector Caroline Baker Unannounced Inspection 21 February 2006 09:50 st Clarence Park Lodge DS0000008103.V277898.R01.S.doc Version 5.1 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 Clarence Park Lodge DS0000008103.V277898.R01.S.doc Version 5.1 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. Clarence Park Lodge DS0000008103.V277898.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Clarence Park Lodge Address 15 Clarence Road East Weston Super Mare North Somerset BS23 4BP 01934 623867 01934 620575 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) Western Counselling Services Limited Mr John Alun Davies Care Home 14 Category(ies) of Past or present alcohol dependence (14), Past or registration, with number present drug dependence (14) of places Clarence Park Lodge DS0000008103.V277898.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 14 persons aged 17-64 years requiring personal care only. 7th October 2005 Date of last inspection Brief Description of the Service: Western Counselling Services is registered with the Commission for Social Care Inspection (CSCI) and provides primary and secondary programmes of rehabilitation for up to 65 people between the ages of 17 and 64 years who have alcohol and/or drug dependencies. The bulk of the primary counselling programme takes place at a day centre and there are two houses (Meijer and St Davids), which provide accommodation for mixed sex groups on primary programmes. Three other houses, Larkhill, Kintyre and Clarence Park Lodge provide accommodation for single sex groups receiving secondary programmes. Clarence Park lodge provides up to 14 places. The counselling is based upon the twelve-step Minnesota model. These homes have a private arrangement with a local GP practice to provide medical support and assessments, especially for those who are in the initial part of the primary programme. Clarence Park Lodge DS0000008103.V277898.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report should be read in conjunction with the reports of the other homes run by Western Counselling Services (WCS). At the time of this inspection the whole service was providing primary care to 18 clients and secondary care to 14 clients. This inspection was unannounced and took place over one day (11.5 inspector hours) by two inspectors - Caroline Baker and Sue Fuller – Pharmacist Inspector. At the time of this inspection the requirements issued at the last inspection had been complied with and the recommendations had been actioned. This house can accommodate up to fourteen clients. There were 6 clients in residence at the time of this inspection. A brief assessment of the premises took place. This report should be read in conjunction with the last inspection report when a full assessment of the premises took place. All of the clients were spoken with. The registered manager was available throughout the inspection. Records relating to the clients, staff and health and safety were examined. What the service does well: WCS provides excellent information for clients in the format of a Statement of Purpose/Service User Guide (Welcome Pack) giving prospective clients a full guide to the service and its philosophy. The majority of clients told inspectors that there were no surprises. Clients are fully assessed on referral to the service and have an opportunity to visit WCS to complete the assessment before admission. A call contact system is then put into place to ensure clients and the service knows when the admission will be. Many clients are taken on telephone assessments, which are very thorough, and depending where the client comes from. As well as considerable group therapy the programme also provides I:I counselling twice weekly or more if required, topic workshops, and diary groups for example. WCS continues to have an open and inclusive atmosphere, everyone appeared relaxed and cheerful. Staff morale was very good. The interaction between staff and clients was happy and relaxed. Clients spoke highly of the counsellors. Clarence Park Lodge DS0000008103.V277898.R01.S.doc Version 5.1 Page 6 The home ensures that all clients have access to appropriate health care professionals and will offer support to attend appointments where appropriate. Feedback from clients during the inspection was very positive with regard to all aspects of the provision of counselling and support at WCS. They understood the rules and boundaries and accepted them as part of the intense programme offered at the home. Comments received included: “The food is excellent”, “the counsellors are fantastic, all differ but all do well”, “ the houses are clean and comfortable”, “the programme really helps”, “a very rewarding process, I have learned a lot about myself” and “the staff are caring”. The discharge rate at the home remains low indicating a very good success rate. Clients also benefit from an aftercare service, which allows them to keep in touch with the counsellors once they have completed. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Clarence Park Lodge DS0000008103.V277898.R01.S.doc Version 5.1 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 Clarence Park Lodge DS0000008103.V277898.R01.S.doc Version 5.1 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): 1 and 2. Western Counselling Services (WCS) was able to demonstrate that clients are fully assessed prior to admission to ensure their needs can be met. WCS has systems in place to introduce prospective clients to the service, other clients and the programme prior to admission. EVIDENCE: WCS has a detailed Statement of Purpose (Welcome Pack), which is provided to all potential clients. It provides details of WCS’s philosophy, therapeutic programmes, facilities and timetable of activities. A service user guide is available for female and male clients, primary and secondary clients. Clients consulted during this inspection felt that the information provided reflected service provision and enabled them to make an informed choice regarding admission to the programmes. A telephone referral normally starts the process to admission to WCS and the programmes. Referral and assessment forms for three clients were examined as part of the inspection process. All potential clients are invited to WCS for an assessment meeting following the initial referral, which is normally conducted, by the admissions liaison officer at WCS. Clients consulted confirmed this process. They are able to stay for a meal and meet other clients. Clarence Park Lodge DS0000008103.V277898.R01.S.doc Version 5.1 Page 9 A detailed assessment form is completed and takes into account a life history, pattern of addiction, physical and mental health, significant others and family and also any special needs. Evidence was seen that WCS had clear criteria for admissions. Where required staff will liaise with other health care professionals in deciding whether a placement is appropriate. This was discussed in depth during inspection given one referral with potential complicated health needs. The inspectors advised the managers to question decisions made by health care professionals if medical needs were complex or posed high risk. Clarence Park Lodge DS0000008103.V277898.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6; 7; 8 and 9. WCS’s care planning system demonstrated that care plans are kept under review. Clients are involved in all aspects of life within WCS. Clients were supported to make decisions and to live a lifestyle in accordance with their plan of care, risk assessments were carried out but plans of minimising risks were not completed. EVIDENCE: Three individual clients’ care records were seen. They included client identification and assessment forms together with their photographs. A comprehensive assessment had been undertaken and care records confirmed regular in depth 1:1 meetings with counsellors. Within the therapeutic programme, the aim is to enable and empower individuals. Clients consulted indicated that strict WCS house rules imposed were necessary for their well being. Clarence Park Lodge DS0000008103.V277898.R01.S.doc Version 5.1 Page 11 The day-to-day running of WCS is organised by the counsellors at the day centre for those in primary care. Boundaries are set for those in secondary care and are designed to allow greater flexibility. One client in each house is allocated group leader and they liaise on a daily basis with management. Individual risk assessments were seen in the care records examined and action plans had been devised in regard to minimising the risks as required at the last inspection. It was evident as part of the programme clients are encouraged and enabled, within the set boundaries, to be self-aware and afford themselves a greater choice in how they live without mood altering substances. Clarence Park Lodge DS0000008103.V277898.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11; 13; 14; 15; 16 and 17 Clients benefit from good support, which enables them to personally develop, enjoy a range of leisure activities and to access local community facilities within set boundaries once in the secondary part of the programme. Clients were offered a choice of menu and wholesome food. EVIDENCE: One of the inspectors met with clients both in primary and secondary care to gain their views on service delivery. At WCS clients are expected to abide by set strict rules, which are challenging to enable them to physically and mentally recover from their addiction. Each house has a housekeeper to keep it clean and tidy and a cook to prepare and serve meals to the clients staying in them. Clients are expected to attend to their own personal laundry. Throughout the week there is a restriction on television viewing encouraging clients to spend more time in peer support and group activities. Clarence Park Lodge DS0000008103.V277898.R01.S.doc Version 5.1 Page 13 Each day is structured and begins with a ‘meditation group’ at the day centre for primary care clients. The counsellors are given the opportunity during these groups to ascertain any concerns or issues arising from the previous evening or night. Then there are ‘group therapy’ sessions, educational videos and lectures in addition to 1:1 counselling at least twice weekly. Clients consulted confirmed the programme routine. Since the last inspection and as recommended the provider has ensured the length of time between group sessions has been fulfilled by a further activity. Primary care clients have an opportunity to go for a walk in the local parks at the weekends and partake in group sports. Physical exercise is restricted as part of the structured programme, there is no gym facility at WCS. Secondary care clients can access the local college and undertake voluntary work. They are given support to attend AA/NA support groups in the local community weekly as a preparation for their transfer. Those spoken to at Clarence Park Lodge and Kintyre confirmed this. Contact with family is restricted during the first week but subsequent arrangements for visits and telephone calls are agreed with the Counsellor as part of the overall care programme. There are restrictions imposed during the programme to protect the interests of the individual and the group. House rules are made explicit on admission and breach of these usually leads to exclusion to the programme. Clients told the inspectors during a group discussion, that the rules were fair and essential to the integrity of the programme. There is a two-week rotating menu and clients told inspectors that they had a choice and were able to help with choosing the menus. Evidence was seen of a regular supply of fresh fruit and vegetables. All house kitchens assessed were clean and tidy. All of the clients consulted with praised the provision of food at WCS. During the secondary programme clients are expected to cook for themselves at weekends. Clarence Park Lodge DS0000008103.V277898.R01.S.doc Version 5.1 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 and 20. Clients receive a very good level of support to meet their physical, emotional and health care needs. Many improvements have been made to the medicine handling in this service however, some amendments to the medication system are needed to ensure that they comply with current legislation and do not place clients at risk of medication errors. EVIDENCE: There were no clients requiring personal care at the time of this inspection. A daily programme in primary care consists of three group therapy sessions, 1:1 counselling and therapeutic workshops. There are clear restrictions made in regard to times of going to bed and getting up as part of the structured programme. Clients informed the inspector that they found this tough at times but understood the reasons behind the strict rules. Clarence Park Lodge DS0000008103.V277898.R01.S.doc Version 5.1 Page 15 It was rewarding to meet clients in the secondary part of the programme who had almost completed the programme and were looking forward to starting a better life. The Pharmacist Inspector assessed the medication systems at WCS. An additional more detailed report has also been provided for staff. The primary stage of treatment lasts up to 12 weeks and can incorporate a programme of medication for withdrawal as necessary. The Service user Guide States: - The therapeutic programme is abstinent based, 12 step model, use of non-prescribed medications, illicit substances or alcohol is strictly forbidden and will result in discharge. Any medicinal requirements are made through the doctor who will ensure appropriate prescribing. Clients are registered with doctors from one local GP practice. Some standard medication used in the centre, including some Prescription Only Medicines (POMs), is supplied as a stock for the doctor’s practice. All other medication is prescribed and dispensed by the pharmacy for individual clients. There was some discussion about this practice. Care homes registered without nursing cannot hold stocks of POMs. If the current system were to continue action would have to be taken to ensure that the POMs were kept separately as the doctor’s stock. There was some discussion about whether all these medicines could be prescribed for individual clients reducing the need to keep stock medication and this is to be discussed with the doctors involved. All medication is stored centrally in locked medicine cupboards. Nomad boxes are transferred to locked storage in another house for nighttime and weekend administration. Any When required medication and homely remedies transferred to the house must remain in the original labelled container to ensure that staff administering the medication can check that they are giving it correctly. No separate medicine fridge is available. If a domestic fridge without a lock is used to store medicines they must be kept in a locked container within the fridge to ensure that only those staff trained in medicines administration have access to them. Doctor transfers medicines to weekly Nomad boxes for each client and staff administer medicines from these. No record is kept of the person making up the boxes. The boxes seen were labelled with the clients name and date of birth but had no indication of what medicines they contained. To ensure safe administration staff must be able to check the medicines label with the medicines administration record sheet before administration. Action must be taken to ensure that the Nomad boxes are fully labelled. Records should be kept of the person who makes up each box. A number of medicines are used on a When required basis after confirming the need for them with the doctor. Clarence Park Lodge DS0000008103.V277898.R01.S.doc Version 5.1 Page 16 It is recommended that a policy for the use of homely remedies is prepared and agreed with the doctors. POMs may not be used as homely remedies. Medicine administration was not observed during this inspection. Written procedures for administration and prescribing have been written. It is recommended that staff produce a medicines policy for the service, which covers all areas of medicine handling. The doctor records each client’s medication on a card. It is recommended that staff ensure that all entries are signed to provide written evidence of the doctor’s prescription. Staff have devised a medicines administration record sheet to suit the needs of their clients. The doctor signs these sheets. Action must be taken to ensure that records of all medicines administered to the client are made on the sheet. Some injections are self-administered; a record of this must be made on the medicines administration record sheet. Records are kept of medicines received and disposed of. The disposal record must be amended to include the signature of the member of staff making the entry. All support workers involved with medication have been booked on to courses for medication handling at Weston College. This course leads to a certificate in Safe Handling of Medicines Level 2. Following this inspection a protocol for homely remedies and their administration has been prepared. The policy for prescribing, recording and storage has been updated. Aftercare is provided free of charge and occurs weekly. It is available to any individual who completes the programme, for as long as necessary. Clients consulted with confirmed that ex-clients attend the centre and give positive feedback to new clients. Clarence Park Lodge DS0000008103.V277898.R01.S.doc Version 5.1 Page 17 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. Appropriate steps were taken to reduce the risk of harm or abuse to clients. EVIDENCE: All clients receive a copy of the home’s complaints procedure and it is displayed at each house. Clients consulted were aware of the complaints procedure. WCS has a complaints record book and there had not been any recorded since the last inspection. Policies were in place for the protection of vulnerable adults. There had not been any adult protection issues raised. Clarence Park Lodge DS0000008103.V277898.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Clients stay in a homely, clean environment where they may share a bedroom and can socialise in a variety of communal areas. WCS’s primary care provides a day centre for clients to meet on a daily basis. EVIDENCE: Clarence Park Lodge is registered with the CSCI and provides accommodation for up to 14 clients. There were 6 clients seen at the house and one showed the inspector briefly around the home. The rooms seen at the house were clean, tidy, personalised, and were decorated and furnished to a high standard. Some rooms were shared and some had en-suite facilities. All rooms had a wash hand basin and were close to toilet and bathing facilities. The laundry room had adequate facilities to allow clients to undertake their own personal washing. The garden was pleasant with sitting areas for the clients to enjoy within the set boundaries of the home. Clarence Park Lodge DS0000008103.V277898.R01.S.doc Version 5.1 Page 19 Refurbishment of the houses is on going and evidence was seen of investment into each house by the high standard and upkeep of the outside, the new carpets, furniture, and décor. Clarence Park Lodge DS0000008103.V277898.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32; 34 and 35. The skill mix of staff at WCS was good and staffing levels suit the needs of the clients. Staff morale was very good and staff were supported and competent to do the job they had been employed for. The homes recruitment procedures had improved for the protection of clients. EVIDENCE: One inspector spoke with the one counsellor and volunteer support worker. They confirmed that they had a job description and contract of employment detailing their responsibilities and line of accountability. They were happy at WCS and felt very well supported. All counselling staff had relevant qualifications and experience in the field of addiction. The staff consulted during this inspection had gained or were working towards a Diploma in Counselling. Clients were very positive about the counsellors and felt they were all competent. Clarence Park Lodge DS0000008103.V277898.R01.S.doc Version 5.1 Page 21 WCS is staffed 12 hours per day by counsellors and two registered managers, supported by the providers and administrators. During the evening and at weekends there are accredited support workers on duty with a counsellor always on call. Two staff files were examined as part of the inspection to ensure vulnerable adults were protected by the systems in place. Overall good practise was seen. All staff now had an enhanced CRB in place as required at the last inspection. As discussed interview notes should be recorded to include a risk assessment and rationale for employing persons with disclosures of convictions. Copies of contracts should also be kept within the individual staff files. It is also recommended that staff files are audited on a regular basis to ensure all items are in place in line with Care Home Regulations 2001. Clarence Park Lodge DS0000008103.V277898.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37; 38; 39; 40; 41; 42 and 43. The managers effectively manage WCS and the management style provides an open and inclusive environment for clients and staff. WCS was taking appropriate steps, to ensure the health and safety of clients, staff and visitors. EVIDENCE: WCS management is structured at this time with two registered managers – Mr Alun Davies and Mr Ken Evans. Mr Rob Thomas is the registered individual. Mr Ken Evans is responsible for the day-to-day operation of the primary care programme and accommodation and spent the day of inspection with the Pharmacist Inspector. Mr Alun Davies was available throughout the inspection and he is responsible for the day-to-day operation of the secondary care programme, accommodation and aftercare. Clarence Park Lodge DS0000008103.V277898.R01.S.doc Version 5.1 Page 23 The clients spoke highly of Mr Evans and Mr Davies who have been part of WCS for a number of years and have a wealth of experience. Amanda Lea – provider - is responsible alongside Rob Thomas for the day-today running of WCS and is at this time undertaking the Registered Managers Award (RMA). Once completed, she is considering applying to be overall registered manager of WCS. The atmosphere appeared open and inclusive. Evidence was seen that managers and counsellors to discuss all areas of provision hold regular meetings. Clients confirmed this and indicated that the managers and counsellors were all approachable and available at any time. The discharge processes and rules were discussed. Clients felt that the programme was intense, very strict and rigorous and that WCS was managed appropriately and in a way that safeguarded the interests and welfare of the group. The service had Quality in Alcohol and Drug Services (QuADS) accreditation. Clients confirmed that their views were sought in regard to the structure of the programme and the service provision. The Providers regularly visit the houses and make reports under Regulation 26. The fire logs in each house assessed were examined and indicated regular periodic checks and tests being undertaken. Fire fighting equipment was checked weekly alongside the fire alarms and emergency lighting. The fire alarms and annual fire check of the service was last carried out in July 2005. Staff had received appropriate fire awareness training and the clients were aware of the fire procedures. Kitchen records checked in houses sampled were found to be maintained and current. Access to records is controlled and there is policy guidance with regard to confidentiality and disclosure. A current Employers Liability Insurance certificate was displayed at the day centre and at each house assessed – Expiry April 2006. Clarence Park Lodge DS0000008103.V277898.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 1 X 3 3 3 3 3 3 3 Clarence Park Lodge DS0000008103.V277898.R01.S.doc Version 5.1 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13(2) Requirement Prescription Only Medicines obtained on a doctor’s order for stock must be kept in a separate cupboard for the doctor’s use only. Medication stored in a domestic fridge must be held securely in a locked container. Nomad boxes must be fully labelled so that staff can check the medication before administration. Medication transferred to another house must be in fully labelled containers. All medicines administered must be recorded on the medicines administration record sheet. The person making the record must sign for medicines returned to the pharmacy. Timescale for action 30/03/06 2 YA20 13(2) 30/03/06 3 YA20 13(2) 30/03/06 4 YA20 13(2) 30/03/06 5 YA20 13(2) 30/03/06 Clarence Park Lodge DS0000008103.V277898.R01.S.doc Version 5.1 Page 26 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 YA20 Good Practice Recommendations It is recommended that staff produce a medicines policy for the service, which covers all areas of medicine handling. It is recommended that staff files are audited on a regular basis to ensure all items are in place in line with Care Home Regulations 2001. 2 YA34 Clarence Park Lodge DS0000008103.V277898.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Clarence Park Lodge DS0000008103.V277898.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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