Inspection on 21/04/06 for Gothic Lodge

This inspection was carried out on 21st April 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 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 10 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 12/02/08

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 08/07/2008.

CARE HOME ADULTS 18-65 Gothic Lodge 21 Idmiston Road West Norwood London SE27 9HG Lead Inspector Sonia McKay Unannounced Inspection 21st April 2006 08:00 Gothic Lodge DS0000022732.V291212.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 Gothic Lodge DS0000022732.V291212.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. Gothic Lodge DS0000022732.V291212.R01.S.doc Version 5.1 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) L`Arche Lambeth Astrid Leonore Ubas Care Home 6 Category(ies) of Learning disability (0), Physical disability (0) registration, with number of places Gothic Lodge DS0000022732.V291212.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th December 2005 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 CSCI 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. Gothic Lodge DS0000022732.V291212.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The record of an unannounced inspection of the service informs this report. One inspector carried out the nine-hour inspection over one day. Four service users, five members of staff and a visiting clinician provided information. Written information was examined and there was a tour of the home. The registered provider also provided the CSCI with information about the service by email, a pre-inspection questionnaire, monthly reports and a community newsletter. What the service does well: What has improved since the last inspection? Radiators have been fitted with covers in some areas to prevent burns. Some of the fire doors have been fitted with special door guards that allow them to be held open but still close if there is a fire. This has helped one service user, who uses a wheelchair, to move around the ground floor easily. Gothic Lodge DS0000022732.V291212.R01.S.doc Version 5.1 Page 6 Hallway lighting on the ground floor is now working properly and two fire doors have been repaired to make sure that they close properly. There are more staff in the team and they do not work for too many hours. This means they are less tired and happier. 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. Gothic Lodge DS0000022732.V291212.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 Gothic Lodge DS0000022732.V291212.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, 2, 3, 4 & 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users have the information they need to make an informed choice to live in the home. All new service users receive a comprehensive needs assessment before admission and significant time and effort is spent making admission to the home personal and effective. Staff are trained to provide services for people with learning disabilities, but do not have sufficient knowledge to meet the cultural needs of specific minority groups in some cases. Accessible contracts of occupancy are not all in place but are being developed. 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. New service users are admitted on the basis of a full assessment of needs. The registered manager obtains a copy of the care needs assessments carried out by health and social services as part of this process. Gothic Lodge DS0000022732.V291212.R01.S.doc Version 5.1 Page 9 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 service user with ample opportunity to experience life in the home before making a decision to move in for a trial period. Staff receive training in supporting service users with a learning disability and communication needs. They use signed communication and visual aids to enrich clear verbal communication with service users. The needs and preferences of specific religious groups are recognised and catered for. However, the ethnic mix of the current staff team does not reflect that of the service users. This presents a challenge to the team in fully recognising and meeting the cultural needs and preferences of one of the service users. (See requirement 1 & recommendation 1) Written contracts are not in place for each of the service users. 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) Gothic Lodge DS0000022732.V291212.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, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each service user has a comprehensive written care plan and can make decisions about daily life and contribute to setting future goals with assistance as needed. Risks are assessed and effectively managed and confidential information is handled appropriately. EVIDENCE: Individual care plans are reviewed annually and every six months new goals are reviewed/set by the service user and key staff. Service users choose whom to invite to the annual review, this may include family members and a LArche advocate. L’Arche are developing visually accessible plans appropriate to the communication needs/preferences of individual service users. Care plans are appropriate and detailed. Placing authorities also review the care provided to individuals, usually as part of the annual care review. Gothic Lodge DS0000022732.V291212.R01.S.doc Version 5.1 Page 11 There is evidence that the service revises care plans and requests additional reviews to address specific issues when appropriate. For example, if needs change or multidisciplinary discussion is required in an area of concern or in a service users best interests. The home manager is developing a plan to address areas of inadequate personal care raised during a recent social services care review. L’Arche uses a semi-independent advocacy system with people who know the service user well. This ensures that someone from outside the service is involved. L’Arche aims to provide the services of fully independent advocate if a service user requires assistance with major decisions. Involving service users in decision making is a LArche priority for 2006/07. Service users are encouraged to participate in the day-to-day running of the home and in community planning. They take part in weekly house meetings, ‘talking group’ meetings with the director nine times a year, community council elections and other community gatherings. Service users are involved in the assessment of new staff during their probationary period and increased involvement in staff appraisal is being developed. Service users are involved in setting the priorities for the Community as a whole and in the formal review of the day services. Service users 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 own finances. Service users are encouraged to participate in the day to running of the home and in community planning. They can take part in weekly house meetings, ‘talking group’ meetings with the director six times a year and community council elections. Service users are also involved in the assessment of new staff during their probationary period. The manager and staff are clear that service users are entitled to take risks as part of developing a more independent lifestyle. The manager has devised 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 and reviewed regularly. 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. Confidential records are stored securely and staff demonstrate an awareness of when information given to them in confidence should be shared with managers or others. Gothic Lodge DS0000022732.V291212.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): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users 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. Service users are offered a healthy diet and enjoy most of their meals and mealtimes, although culturally appropriate cuisine should be researched and offered more often. EVIDENCE: L’Arche is a faith-based community that offers active support to each service user to develop their faith and spiritual lives. Service users who choose not to attend religious activities of any particular denomination are offered opportunities to engage in art, music and nature. Four of the service users have a place in the workshops (weaving, stone work, gardening and candle making) and another attends a local authority day centre. Service users said that they enjoy their daytime activities. Gothic Lodge DS0000022732.V291212.R01.S.doc Version 5.1 Page 13 The proximity of the other L’Arche homes provides a close community. Service users regularly have supper invitations with 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 the service users. All service users are offered a minimum 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 service users to maintain and develop family relationships. One service user said that he was happy to be going to stay with his brother for the weekend. Observed interactions between staff and service users were respectful, natural and caring. Records of the meals prepared show that a range of meals is served. Food stocks are stored appropriately and include plenty of fresh fruit and vegetables. Each service user chooses and helps to prepare an evening meal to the best of their ability and staff and service users eat main meals together at a large dining table, often with friends. Service users also make snacks and drinks without support if they are able. Two service users said that they liked the meals and one said they were Alright. One service user also enjoys a regular lager and pizza night with a dinner guest. Culturally appropriate meals for one service user do not feature regularly on the menu. A member of staff said that although staff have attempted to prepare culturally appropriate meals for one service user, the meals have not been well received. Meals prepared by a member of the service users family are enjoyed. This indicates that staff may need more skill/knowledge in this area. (See requirement 1) Gothic Lodge DS0000022732.V291212.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, 19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users receive personal support in the way they prefer but in one case there is a need to ensure that culturally appropriate personal care needs are fully addressed. The physical and emotional needs of service users are met but more must be done to ensure that medication is administered in accordance with procedures to ensure safety. EVIDENCE: Service users are well dressed, in styles that reflect their personal choice and personality. Staff provide assistance to select clothes that are appropriate to the weather and activities planned. A member of staff who is the same gender as the service user 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. Gothic Lodge DS0000022732.V291212.R01.S.doc Version 5.1 Page 15 One service user is Afro-Caribbean and is need of additional support to maintain appropriate hair and skin care. (See requirement 1) 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 service users. Staff support service users 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 service user has to be taken to hospital in an emergency. This is good practice. There is evidence that service users general healthcare and individual healthcare needs are met and records are kept of the outcomes of appointments. The Lambeth specialist team for adults with a learning disability provides input on referral. Input includes psychology, physiotherapy and speech and language therapy. The team physiotherapist said that staff communicate well with the team, request advice promptly and follow recommendations and any exercise programmes provided. There is evidence that the home manager requests multi-disciplinary input in the ‘best interests’ of any service users who needs general anaesthetic for essential healthcare. All service users require staff support to take their medication. All medication is stored securely and administered by staff. 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 service user, what they have been prescribed and what each medication is used for. Four members of staff are trained to administer medication. A previous requirement to seek advice from the GP in regard to appropriate ‘homely remedies’ (over the counter items for minor ailments) for each service user has not yet been met. (See requirement 3). One service user is prescribed topical medications to be used during personal care and bathing. A member of staff said that he had assisted the service user to use these products for three consecutive days although he had not recorded Gothic Lodge DS0000022732.V291212.R01.S.doc Version 5.1 Page 16 the administration. There was also a gap in recording the administration of another medication (a thyroxine 125mcg tablet) on 06/04/06. (See requirement 4) Another service user takes an analgesic when required. The medication administration record does not detail the maximum dose that can be taken in twenty-four hours and the directions for use of another when required medication says see guidelines. The dose should be specified. (See recommendation 2) Gothic Lodge DS0000022732.V291212.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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users views 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 service users 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 CSCI. Regular house meetings provide service users with an opportunity to raise concerns. The home manager has arranged the complaints book so that the timescales of any complaints investigation are recorded, as required in the previous inspection report. 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. A staff member on duty had a thorough knowledge of signs of abuse, forms of abuse and action to take if she witnessed or suspected abuse, although some staff are not familiar with the local authority adult protection procedures. It is recommended that an up to date copy of the Lambeth adult protection procedures be obtained for staff reference. (See recommendation 3) Gothic Lodge DS0000022732.V291212.R01.S.doc Version 5.1 Page 18 All service users require assistance with financial issues. Receipts are retained for all transactions and stored with the individual accounts that were in good order. A record of visitors is available and is being used appropriately. Gothic Lodge DS0000022732.V291212.R01.S.doc Version 5.1 Page 19 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, 25, 26, 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a comfortable and homely environment and have bedrooms that suit their needs and lifestyles. Toilets and bathrooms provide sufficient privacy and meet individual mobility needs where necessary. Shared spaces complement and supplement individual room. Although fire safety has improved, failure to ensure that fire doors are not wedged open presents a fire hazard. 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 service user with a mobility need. However, doors are missing from a Gothic Lodge DS0000022732.V291212.R01.S.doc Version 5.1 Page 20 cabinet in one first floor bedroom and the service user 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, although quotes are being gathered. (See recommendation 4) 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 service user who uses a wheelchair to move around the building with ease. Fire doors to other rooms are sometimes still propped open (the laundry room and a service users bedroom door on the first floor). This is a fire hazard. (See requirement 5) Gothic Lodge DS0000022732.V291212.R01.S.doc Version 5.1 Page 21 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): 31, 32, 33, 34, 35 & 36 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 service users although, as yet, this does not include a national vocational qualification in Care. Recruitment procedures are adequate and staff are well supervised and supported. 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. A new duty pattern has been introduced to ensure that staff have adequate time off. This has increased the number of staff in the team by two members. 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 Gothic Lodge DS0000022732.V291212.R01.S.doc Version 5.1 Page 22 and needs of the service users. Two members of staff are on duty, but asleep, during the night. 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 service users 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) 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. Recruitment records examined were in accordance with regulation. 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 service users, is available. Training includes gentle teaching, activities and skills development, challenging needs, autism, and sensory impairment. Gothic Lodge DS0000022732.V291212.R01.S.doc Version 5.1 Page 23 Mandatory training includes first aid, health and safety (including epilepsy), food hygiene, manual handling, Sign-along and medication administration. Records of supervision meetings between the assistants and the home managers are maintained and provide evidence that meetings are held regularly. Staff said that they felt adequately supported and that there were always senior staff available by telephone if they needed advice. Staff team meetings are regular and documented. The home manager is trained in supervision and supervises each member of staff working at the Gothic Lodge. A member of staff said that she felt supported and had adequate opportunity to discuss any concerns and contribute ideas. Supervision meetings are held regularly and a record kept of issues discussed. LArche also provides each member of staff with a member of the community from outside of their home base to provide additional support. Gothic Lodge DS0000022732.V291212.R01.S.doc Version 5.1 Page 24 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 & 43 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home manager is competent and staff appreciate her leadership and management approach. Although there are systems in place for service users to contribute to the running of the organisation the registered provider has failed to monitor the home with the required regularity and more must be done to ensure the health and safety of service users and staff. EVIDENCE: The registered home manager has been in post for a year and has decided not to undertake an NVQ qualification in Care and management as she intends to pursue an alternative career in the later part of 2006. A member of staff said that her management style is inclusive, supportive and positive. The registered provider is taking steps to recruit a new home manager. Records are kept as required. Gothic Lodge DS0000022732.V291212.R01.S.doc Version 5.1 Page 25 The L’Arche community has an annual development plan for quality assurance in place although the home has 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. (See requirement 8) Regular house and community meetings are held to ensure that the views of the service users impact on the running of the community and planning home life. Policies and procedures are reviewed regularly and a number have been reviewed or developed in 2004/5, including physical restraint, challengingbehaviour, risk assessment, internal incident reporting, internal financial controls, confidentiality, medication, visitors, transport and recruitment. L’Arche has demonstrated that policy and procedure are reviewed in light of changing circumstances. Staff conduct regular health and safety checks of the premises and record the outcomes. An environmental risk assessment is reviewed annually. The Annual Landlords Gas Boiler safety certificate was issued on 21/12/05. Mains electric circuitry has been safety checked on 05/07/02. The test certificate covers a five-year period from that date. Small electrical appliances have been safety tested by a trained house assistant on 4th March 2005. This test is now overdue. (See requirement 9) 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. Only two fire evacuation drills have been conducted in the last 12 months. This is not frequent enough. (See requirement 10) 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. Gothic Lodge DS0000022732.V291212.R01.S.doc Version 5.1 Page 26 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 2 4 3 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 2 25 3 26 2 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 3 3 2 3 3 2 3 Gothic Lodge DS0000022732.V291212.R01.S.doc Version 5.1 Page 27 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 YA3 Regulation 12(4)(b) Requirement The registered persons must demonstrate the ability to recognise and meet the specific cultural needs and preferences of one of the service users currently accommodated. The registered persons 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 persons must ensure that advice is sought from the GP in regard to appropriate ‘homely remedy’ medicines for each service user. Evidence of agreed medicines and their administration must be maintained in medication records. Previous timescales of 30/09/05 and 03/03/06 not met. The registered person must ensure that there is an DS0000022732.V291212.R01.S.doc Timescale for action 31/08/06 2. YA5 5(3) 12(5)(a) 31/08/06 3. YA20 13(2) 30/06/06 4. YA20 13(2) 17(1)(a) 30/06/06 Gothic Lodge Version 5.1 Page 28 5. YA26 23 6. YA42 23(4) 12(1) 7. YA32 18(1) accurate and clear record of any medication prescribed and/or administered. Previous timescale of 03/02/06 not met. The registered persons 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. The registered persons must ensure that fire doors are not wedged open. Previous timescale of 30/12/05 not met. 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. The registered persons must ensure that small electrical appliances are safety tested annually and a record kept of the test result of each item tested. The registered persons must ensure that fire evacuation drills are DS0000022732.V291212.R01.S.doc 31/08/06 30/06/06 31/08/06 8. YA39 26 31/08/06 9. YA42 23(2)(c) 30/06/06 10. YA42 23(4)(e) 30/06/06 Gothic Lodge Version 5.1 Page 29 conducted at least four times each year and more often if required. 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 Refer to Standard YA33 YA20 Good Practice Recommendations The registered person should take steps to ensure that the staff team reflects the cultural composition of the service user group. The registered person should ensure that the maximum dose of As Required analgesics that can safely be administered within 24 hours and clear directions for the dose of any as required medications are detailed on medication administration records. The registered persons should obtain a copy of the Lambeth Adult Protection Procedures and keep it in the home for staff reference. The registered person should have a pest control contract. 3 4. YA23 YA30 Gothic Lodge DS0000022732.V291212.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 Gothic Lodge DS0000022732.V291212.R01.S.doc Version 5.1 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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