Inspection on 12/02/08 for Gothic Lodge

This inspection was carried out on 12th February 2008.

CSCI found this care home to be providing an Adequate service.

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

Other inspections for this house

Gothic Lodge 02/12/09

Gothic Lodge 08/12/08

Gothic Lodge 21/04/06

Gothic Lodge 06/12/05

Gothic Lodge 04/07/05

Gothic Lodge 07/03/05

Gothic Lodge 03/09/04

Gothic Lodge 24/03/04

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 08/11/2008.

CARE HOME ADULTS 18-65 Gothic Lodge 21 Idmiston Road West Norwood London SE27 9HG Lead Inspector Sonia McKay Key Unannounced Inspection 12th February 2008 09:30 DS0000022732.V350417.R02.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 DS0000022732.V350417.R02.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. DS0000022732.V350417.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gothic Lodge Address 21 Idmiston Road West Norwood London SE27 9HG 020 8761 8044 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) gothiclodge@yahoo.co.uk www.larche.org.uk L`Arche Lambeth Care Home 6 Category(ies) of Learning disability (0), Physical disability (0) registration, with number of places DS0000022732.V350417.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st April 2006 Brief Description of the Service: Gothic Lodge is a large detached gothic style house with three floors. It is located in a residential road in West Norwood close to the organisations workshops, high street shopping and transport networks. The home is registered to provide care and accommodation for six adults with a learning disability. Accommodation is also provided for staff who provide support within the home and to other LArche staff. The house is spacious and is surrounded by a reasonably sized garden. The organisations gardening workshop is adjacent to the home. The home is one of a group of homes managed by L’Arche Lambeth, an Ecumenical Christian Community that welcomes people of all faiths and people of no stated faith. Strong emphasis is placed on the ‘community’ of staff and service users. Prospective service users receive an information pack about the service and a copy of the most recent Commission inspection report is available on request at the home. Current fees range between £433.60 and £517.39 per week and depend on the support needs of individuals placed. DS0000022732.V350417.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced key inspection was carried out in six hours by one inspector. The methods used to assess the quality of service being provided include: • • • • • • • • • Discussion with the newly appointed home manager Examination of the Annual Quality Assurance Audit document completed by the manager (this document is sometimes called an AQAA and it provides the Commission with information about the service) Discussion with one person currently living in the home Observation of the care and support that another resident received A tour of the premises Visiting a community gathering attended by some of the residents living in this service Examining records of the care provided to two of the residents Examining records relating to staffing and training Examination of the way medicines are handled by staff in the home The Commission would like to thank all who kindly contributed their time, views and experiences to this inspection process. What the service does well: The aspirations and needs of prospective residents are fully assessed before they are offered a placement in the home. People’s assessed and changing needs, including personal goals, are reflected in written plans for care and support. Each resident is given appropriate support to help them to make important decisions. Residents are able to take part in a wide range of leisure activities and therapeutic employment. Staff help residents to maintain and build appropriate relationships with family and friends. Residents are offered a healthy diet and mealtimes are enjoyable social gatherings. DS0000022732.V350417.R02.S.doc Version 5.2 Page 6 Residents receive appropriate support with personal care and healthcare and are they are kept safe by the procedures in place for staff to follow when administering medication. The views and concerns of residents are listened to and acted upon and they are protected from abuse, neglect and self-harm. Residents live in a comfortable and homely environment. The home is clean and there are no unpleasant odours. Systems to promote environmental safety are in place. What has improved since the last inspection? What they could do better: Information provided to people who are using the service must be revised to include more information about fees and what they are used for. People are supported to take risks as part of developing their independence, however staff must better assess the risks involved and review the written assessments more often, to ensure that residents are safely supported. The staff check the environment often to make sure it is safe but more must be done to assess risks relating to hot surfaces, such as radiators. Staff have clearly defined roles. Steps are being taken to ensure that staff are equipped with the specialist training required to meet the needs of the residents although, as yet, this does not include a national vocational qualification in Care. Recruitment procedures are adequate. DS0000022732.V350417.R02.S.doc Version 5.2 Page 7 The new manager is yet to be registered with the Commission, although she is familiar with the community and service. Systems are in place to check on the quality of the service being provided, although the reports of the outcomes of monitoring visits must be shared with the home manager to ensure that any problems identified are fully addressed. 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. DS0000022732.V350417.R02.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 DS0000022732.V350417.R02.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 & 5. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Information provided to people who are using the service must be revised to include more information about fees and what they are used for. The aspirations and needs of prospective residents are fully assessed before they are offered a placement. EVIDENCE: There is an informative ‘Statement of Purpose’ and a ‘Service Users Guide’. Emphasis is placed on making the guide accessible to service users with a learning disability and it contains many colour photographs, symbols and clear language. The information provided to people using the service must be revised in accordance with recent changes in the Care Homes Regulations of 2001 that came into force in September 2006. The ‘Service Users guide and associated individual contracts must provide greater detail relating to the standard package of services provided. The terms and conditions (including fee levels) that apply to key services (both personal DS0000022732.V350417.R02.S.doc Version 5.2 Page 10 care and food) and the payment arrangements (resident contribution/local authority contribution) must be stipulated. The guide must also state whether the terms and conditions (including fees) would be different in circumstances where a person’s care is funded, in whole or in part, by someone other than the resident. (See requirement 1) New residents are admitted on the basis of a full assessment of needs. The manager obtains a copy of the care needs assessments carried out by health and social services as part of this process. Only long- term placements are offered and there is a lengthy placement process. This is tailored to meet the needs of the individual and usually involves at least two brief visits to the home and three longer visits, including overnight stays. This provides the prospective resident with ample opportunity to experience life in the home before making a decision to move in for a trial period. There are no new residents and the service is currently fully occupied. During the previous inspection it was noted that the needs and preferences of specific religious groups were recognised and catered for. However, the ethnic mix of the staff team did not reflect that of the residents. This presents a challenge to the team in fully recognising and meeting the cultural needs and preferences of one of the residents, who is Afro-Caribbean. (See recommendation 4) During this inspection it is noted that the staff have made an effort to work with family members to ensure that the persons cultural needs are addressed. The resident has regular contact with family members and staff have amended menus to include a wider range of Caribbean meals and snacks. Written contracts are not in place for each of the residents. The provider is currently reviewing the written contracts or statements of terms and conditions of occupancy with a view to including symbols and making them more accessible. (See requirement 2) DS0000022732.V350417.R02.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 & 9. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People’s assessed and changing needs, including personal goals, are reflected in written plans for care and support and each person is given appropriate support to make decisions if necessary. People are supported to take risks as part of developing their independence, however staff must better assess the risks involved and review the written assessments more often, to ensure that residents are safely supported. EVIDENCE: Individual care plans are reviewed annually and every six months new goals are reviewed/set by the resident and staff. Residents choose whom to invite to the annual review. This may include family members, and key staff. There is progress in developing a circle of support for each person. This is made up of people who the resident well and who can provide support and help with planning and decision-making. DS0000022732.V350417.R02.S.doc Version 5.2 Page 12 L’Arche are developing visually accessible plans appropriate to the communication needs/preferences of individual residents. Care plans are appropriate and detailed. Placing authorities also review the care provided to individuals, usually as part of the annual care review. Residents are encouraged to participate in the day-to-day running of the home and in L’Arche community planning. They take part in weekly house meetings, ‘talking group’ meetings with the director of L’Arche, community council elections and other community gatherings. Residents are involved in the assessment of new staff during their probationary period and increased involvement in staff appraisal is being developed. Residents are involved in setting the priorities for the Community as a whole and in the formal review of the day services. Residents make day-to-day decisions about what to wear, how to spend their leisure time, who to invite to dinner and what to cook. All need assistance to claim state benefits and manage their finances. There is a risk audit tool that assists staff to systematically consider risks posed to individuals during activities of daily living and community participation and to take action to minimise any identified hazards. Individual risk management strategies are developed for any high-risk situations. Some of these individual risk assessments have not been reviewed for over a year. This means that changes in risk may not have been identified and this could place residents in danger. For example, a resident has recently become more mobile and is engaging in new activities but a moving and handling risk assessment has not been reviewed for over twelve months. (See requirement 3) The local behaviour support team for adults with a learning disability provide pro-active and reactive strategies for managing challenging behaviour. Missing Persons procedures are in place and the home responds promptly to any unexplained absences. DS0000022732.V350417.R02.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are able to take part in a wide range of leisure activities and therapeutic employment and appropriate relationships with family and friends are encouraged and supported. Residents are offered a healthy diet and mealtimes are enjoyable social gatherings. EVIDENCE: L’Arche is a faith-based community that offers active support to each resident to enable them to develop their faith and spiritual lives. Residents who choose not to attend religious activities of any particular denomination are offered opportunities to engage in art, music and nature. Current residents attend L’Arche workshops and groups for daytime activities (weaving, stone work, gardening and candle making) and another attends a local authority day centre. DS0000022732.V350417.R02.S.doc Version 5.2 Page 14 The proximity of the other L’Arche homes provides a close community. Residents regularly have supper invitations to see friends living in other homes in the area. L’Arche Lambeth has been operating for more than 25 years and has developed good relationships with local individuals and organisations. Staff live at the Gothic Lodge with the intention of building a shared community with consistent engagement between the staff and residents. All residents are offered a minimum of two weeks of holiday away from the home in each year, either alone (with staff support) or as part of a group with shared interest. There is a range of in-house activities available, including television, videos, music and musical instruments. Evening and weekend activities in the community and at home are also provided. Personal information held in individual care files contains detailed information about family and friends, their birthdays and family history. This enables staff to support residents to maintain and develop family relationships. Observed interactions between staff and residents were respectful, natural and caring. Records of the meals prepared show that a range of meals is served. Food stocks are plentiful and include plenty of fresh fruit and vegetables. Dry goods stored in a pantry are not securely stored, and should be in containers with lids to avoid contamination and pests. (See requirement 4) Each resident chooses and helps to prepare an evening meal to the best of their ability and staff and residents eat main meals together at a large dining table, often with friends. Residents also make snacks and drinks without support if they are able. Culturally appropriate meals feature more often on house menus. One resident enjoys an Italian cooking evening, and staff are becoming more familiar with Caribbean dishes prepared by family members for another resident. DS0000022732.V350417.R02.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents receive appropriate support with personal care and healthcare and are they are kept safe by the procedures in place for staff to follow when administering medication. EVIDENCE: Staff provide assistance to residents to select clothes that are appropriate to the weather and activities planned. A member of staff who is the same gender as the resident provides personal care support. Personal care is provided in the privacy of bathrooms and bedrooms. Preferred bathing routines are clearly laid out in individual plans, detailing the level of support required with each personal care task. During the last inspection it was noted that there was insufficient information about personal care routines for one resident, who is Afro-Caribbean. Staff said that they are now aware of products that are of benefit and the resident is being supported to use moisturisers and hair products. DS0000022732.V350417.R02.S.doc Version 5.2 Page 16 LArche is able to provide a degree of consistent staffing despite regular staff turnover, there are six full time staff (two men and four women) and staff shortfalls, as a result of leave or sickness, are covered by other members of community staff who are known to the residents. Staff support residents to make and attend healthcare appointments. Each persons care file has a detailed health information form to be given to medical staff in the event that a resident is taken to hospital in an emergency. This is good practice. The two sets of records examined provide evidence that that general healthcare and individual healthcare needs are met and records are kept of the outcomes of each appointment. The new home manager has introduced an additional record. This could cause confusion or replication and to make records clearer there should be a single record. (See recommendation 1) The Lambeth specialist team for adults with a learning disability provides input on referral. Input includes psychology, physiotherapy and speech and language therapy. There is evidence that the home manager requests multi-disciplinary input in the ‘best interests’ of any resident who needs general anaesthetic for essential healthcare. There is also progress in looking at the necessity of routine health screenings, such as cervical smears, with health professionals to see if they are needed. All residents require staff support to take their medication. All medication is stored securely and administered by staff, who are trained in safe administration. There are justified weekly stock counts to enable a stock audit trail. This is necessary to identify recording errors and possible misuse. Receipts and returns are recorded in a separate log. There is a medication profile available, which lists each resident, what they have been prescribed and what each medication is used for. A previous requirement to seek advice from the GP in regard to appropriate ‘homely remedies’ (over the counter items for minor ailments) for each resident is met. Each person now has a list of over the counter remedies agreed by their GP and there is a stock of these remedies available in the locked medication cabinet. These lists should be with the GP periodically to ensure that they are still safe. (See recommendation 2) DS0000022732.V350417.R02.S.doc Version 5.2 Page 17 Prescribed medication is supplied in blister packs filled by the pharmacist. All medication is in stock at the time of this inspection. Examination of blister packs and medication administration records indicate that medication is being administered as prescribed and staff are keeping good records. DS0000022732.V350417.R02.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 & 23. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The views and concerns of residents are listened to and acted upon and they are protected from abuse, neglect and self-harm. EVIDENCE: There is a good complaints policy. There is text version and a more accessible version for residents who may not be able to understand a text only document. A complaints poster is displayed on the notice board in a communal area and has colour photographs of people who can assist with a complaint, including the Commission. Regular house meetings provide residents with an opportunity to raise concerns. The home manager has arranged the complaints book so that the timescales of any complaints investigation are recorded. There have been no complaints since the last inspection visit. Abuse awareness training is part of the L’Arche induction and formation training undertaken by all new staff. An up to date copy of the Lambeth adult protection procedures are available for reference, as recommended in the previous inspection report. All residents require assistance with financial matters. Receipts are retained for all transactions and stored with the individual expenditure records. These records are audited by the L’Arche financial controller frequently and are also DS0000022732.V350417.R02.S.doc Version 5.2 Page 19 part of the Regulation 26 monitoring inspections conducted on behalf of the registered provider. This provides residents with safety from financial abuse. A record of visitors is available and is being used appropriately. DS0000022732.V350417.R02.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, 26 & 30. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable and homely environment. The home is clean and there are no unpleasant odours. The staff check the environment often to make sure it is safe but more must be done to assess risks relating to hot surfaces, such as radiators. EVIDENCE: The home is a large, gothic style house with many original features. It is in keeping with other homes in the area and is comfortable, welcoming and reasonably well maintained. Bedrooms are located on the ground floor and first floor of the home. All bedrooms are single occupancy, well furnished and personalised. A profiling bed with a window view is available in the ground floor bedroom of a resident with a mobility need. DS0000022732.V350417.R02.S.doc Version 5.2 Page 21 However, doors are missing from a cabinet in one first floor bedroom and the resident does not have a bedside light or chair. (See requirement 5) Bathroom aids and adaptations are in place where needed and there are a sufficient number of bathrooms and toilets available. There is level access to all communal areas of the home, which are all situated on the ground floor, including access to the garden. The home is clean and satisfactory arrangements are in place for the disposal and handling of clinical waste. Environmental health inspectors visited the home in May 2005 to look at food preparation areas. They made a number of recommendations that have been addressed. One recommendation to obtain a pest control contract is yet to be addressed. (See recommendation 3) Automatic door closures that shut automatically if the fire alarm goes off have been fitted to the fire doors in the ground floor hallway. This enables a resident who uses a wheelchair to move around the building with ease. Fire doors, noted to be propped open with wedges during the last inspection, creating a potential hazard, were observed to be closed during this inspection. A requirement made in this regard is therefore met. One resident is becoming more mobile. A risk assessment must be conducted as to the safety of an unguarded radiator in her bedroom in case she falls and burns herself. (See requirement 6) DS0000022732.V350417.R02.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staff have clearly defined roles. Steps are being taken to ensure that staff are equipped with the specialist training required to meet the needs of the residents although, as yet, this does not include a national vocational qualification in Care. Recruitment procedures are adequate. EVIDENCE: House assistants within the L’Arche community are provided with board and lodgings. Staff at Gothic Lodge live on the premises and take turns to do duty. L’Arche is a community of people with and without learning disabilities who have chosen to live and work together according to a clear set of values. Assistants provide both care and engaged friendship to those they support. L’Arche is a Christian community that requires staff to be part of all aspects of care and support and a committed community lifestyle. Records are kept of all staff duty rosters. Between three and four members of staff are on duty in the home during the daytime depending on the activities DS0000022732.V350417.R02.S.doc Version 5.2 Page 23 and needs of the residents. Two members of staff are on duty, but asleep, during the night. There are also a team of day activities co-ordinators based in an office at the L’Arche head office. These staff arrange activities for residents who do not wish to take part in workshop activities. Recruitment records are held at the L’Arche head office. A recruitment coordinator has made progress in auditing staff recruitment records and has revised the LArche recruitment procedures. As staff live on premises, and are often recruited from overseas, the organisation has not been able to guarantee that the required POVA first check (an initial check against the list of people who are prohibited from working with vulnerable adults) be completed prior to the member of staff commencing work in the home. The registered provider has revised the recruitment and supervision procedures to ensure that risks to residents are minimised. Overseas police checks are obtained before the member of staff commences employment and a POVA first check is applied for on arrival in the UK. Until a satisfactory check is returned the member of staff does not work alone or provide any personal care and is also closely supervised. Recruitment records checked during the inspection included POVA first and enhanced criminal records checks for each member of staff. A framework of policies and procedures provides staff with guidance. There is also ongoing staff support from the homes co-ordinator and other longstanding community staff. As assistants usually only stay for between one and three years they do not normally have an NVQ qualification. The director of L’Arche has conceded that it will be hard for the organisation to meet this standard. One member of staff is currently undertaking a vocational qualification in care (NVQ level 3). (See requirement 7) L’Arche provides all new assistants with induction training in the first six weeks. ‘Foundation training’ is undertaken in the first year, this is a combination of ‘in-house training’ and training provided by the local specialist learning disability team. A training co-ordinator has developed a training needs assessment for staff working at Gothic Lodge and records of training undertaken by individual staff are available. An appropriate range of training, specific to the needs of the DS0000022732.V350417.R02.S.doc Version 5.2 Page 24 service users, is available. Training includes gentle teaching, activities and skills development, challenging needs, autism, and sensory impairment. Mandatory training includes first aid, health and safety (including epilepsy), food hygiene, manual handling, Sign-along and medication administration. DS0000022732.V350417.R02.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, 39 & 42. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The new manager is yet to be registered with the Commission, although she is familiar with the community and service. Systems are in place to check on the quality of the service being provided, although the reports of the outcomes of monitoring visits must be shared with the home manager. Systems to promote environmental safety are in place. EVIDENCE: The registered home manager left in August 2007. A new home manager has been appointed but is yet to complete registration with the Commission. During the last inspection it was noted that the L’Arche community has an annual development plan for quality assurance in place although the home had DS0000022732.V350417.R02.S.doc Version 5.2 Page 26 not been visited on a monthly basis by a representative of the responsible individual as required by Regulation 26 of The Care Homes Regulations 2001. A requirement was issued. During this inspection it is noted that although the frequency of these inspections has increased, copies of the reports detailing the outcomes have not been supplied to the home manager. The requirement is therefore not met. (See requirement 8) Regular house and community meetings are held to ensure that the views of the residents impact on the running of the community and planning home life. Policies and procedures are reviewed regularly. Staff conduct regular health and safety checks of the premises and record the outcomes. An environmental risk assessment is reviewed annually. Small electrical appliances have been safety tested by a trained house assistant, as required in the previous inspection report. Fire authorities inspected the premises on 14/07/04 and action has been taken to meet the requirements made in the report. A fire risk assessment and building floor plan are available. staff test fire alarm call points on a weekly basis and professional equipment tests are conducted periodically. The frequency of fire evacuation drills has been increased, as required in the previous inspection report. This means that residents are given an opportunity to practice what to do in the event of a real fire. Thermostatic hot water safety control mechanisms are fitted to hot water outlets to prevent scalding and accessible radiators are fitted with covers to prevent contact burns in high-risk areas. Window opening restrictors are fitted to prevent falls. DS0000022732.V350417.R02.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 2 2 3 3 X 4 X 5 2 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 2 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 2 X DS0000022732.V350417.R02.S.doc Version 5.2 Page 28 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 YA1 Regulation 5 Requirement The registered person must revised the service users guide in accordance with changes in legislation that require more information about fees and what they cover to be included. The registered person must ensure that service contracts are in place for each service user. Previous timescales of 28/10/05 and 03/03/06 not met. The registered person must ensure that risks posed to residents are reviewed regularly and when their needs change. The registered person must ensure that dry goods are stored in airtight containers to prevent contamination and pest infestation. The registered person must provide each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. Bedrooms should be furnished with all items listed in NMS 26.2. If a service user declines an item, a record must be kept of this decision. DS0000022732.V350417.R02.S.doc Timescale for action 30/06/08 2. YA5 5(3) 12(5)(a) 30/06/08 3. YA9 13(4) 30/04/08 4. YA17 YA30 13(4) 30/04/08 5. YA26 23 30/06/08 Version 5.2 Page 29 6. YA26 13(4) 7 YA32 18(1) 8. YA39 26 The registered persons must conduct an assessment of the risks posed by unguarded radiators in bedrooms. The registered persons must ensure that 50 of care staff hold an NVQ 2 or 3 or are working to achieve one. Previous timescale of 03/02/06 not met. The registered person must ensure that monthly monitoring visits are conducted on the home. The reports of which must be lodged at the home and a copy sent to the CSCI. Previous timescale of 31/12/05 not met. 30/04/08 30/09/08 30/04/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard YA19 YA20 YA30 YA33 Good Practice Recommendations The registered person should maintain a single record of the outcomes of healthcare appointments for each resident. The registered person should ensure that the list of homely remedies agreed by each person’s GP is reviewed with the GP during medication reviews. The registered person should have a pest control contract. The registered person should take steps to ensure that the staff team reflects the cultural composition of the resident group. DS0000022732.V350417.R02.S.doc Version 5.2 Page 30 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup Kent DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000022732.V350417.R02.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. 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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