Inspection on 04/07/05 for Gothic Lodge

This inspection was carried out on 4th July 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 18 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 21/04/06

Gothic Lodge 06/12/05

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 & Vashti Maharaj Unannounced 4 & 5th July 2005 th 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 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 Stationary 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 G52-G02 S22732 Gothic V236768 040705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Gothic Lodge Address 21 Idmiston Road, West Norwood, London SE27 9HG Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8761 8044 LArche Lambeth Astrid Leonore Ubas VO Voluntary 6 Category(ies) of PC Care home only registration, with number of places Gothic Lodge G52-G02 S22732 Gothic V236768 040705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th March 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 organisation’s workshops and to the shopping area of West Norwood. The home is registered to provide single room accommodation for six adults with a learning disability. Accommodation is also provided for staff who provide support within the home and also to two members of workshop staff. The house is very spacious and is surrounded by a reasonably sized pleasant garden especially designed for people with disabilities. The organisations gardening workshop is located 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 also people with no stated faith. Strong emphasis is placed on the ‘community’ of staff and service users. Gothic Lodge G52-G02 S22732 Gothic V236768 040705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection of Gothic Lodge was conducted by two inspectors over the course of two afternoons. Staff recruitment and training records were examined at the L’Arche head office. The inspection involved observing meal preparation arrangements (evening meal), talking with three service users, the registered home manager and staff on duty. Home records and records of the care required and provided to each person were examined. Comments were also received from a professional involved in the care of some of the service users. A tour of the premises, including all of the bedrooms occupied by service users also took place. Comments were also received from a health professional involved in the care of some of the service users. What the service does well: The standard of the environment within this home is good providing service users with an attractive and homely place to live. Emphasis is placed on support with communication. This is suitable for service users with a learning disability who may find text only information inaccessible. Gothic Lodge is one of a group of homes in the area that make up the L’Arche community. There is very strong sense of community within these homes and service users are involved and included in the running of the organisation. Links with the community are good and support and enrich service users’ social opportunities. L’Arche provide workshops and a retirement group that enable each service user to be involved in a range of therapeutic activities in addition to college classes and dayservices provided in the area. The health needs of service users are well met with evidence of good multidisciplinary working taking place on a regular basis. Leisure and holidays are another key feature. Service users commented that they particularly liked the trips and holidays. Support with individual faith and spirituality is a particular focus of the support provided by the L’Arche community. Gothic Lodge G52-G02 S22732 Gothic V236768 040705 Stage 4.doc Version 1.40 Page 6 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. Gothic Lodge G52-G02 S22732 Gothic V236768 040705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Gothic Lodge G52-G02 S22732 Gothic V236768 040705 Stage 4.doc Version 1.40 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 standard(s) 1, 2, 3, 4 & 5. Prospective service users have adequate information to make an informed decision to move into Gothic Lodge, after extensive opportunities to ‘test drive’ the home. Individual needs and aspirations are assessed and met. Service users did not have contracts detailing the terms and conditions with the home. This is not indicative of a professional relationship. EVIDENCE: The home has an informative ‘Statement of Purpose’ and a ‘Service Users Guide’ to the home. Emphasis has been placed on making the guide accessible to service users with a learning disability and it contains many colour photographs, symbols and clear language. The staffing information in the Statement of Purpose is out of date due to changes in the staff team and requires revision. (See requirement 1). L’Arche offers long term placement only and has a lengthy placement process, which 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 allows the refered person the opportunity to experience life in the home before making a positive choice to move in for a trial period. Service users are described as ‘people with learning disabilities in the L’Arche community. Gothic Lodge G52-G02 S22732 Gothic V236768 040705 Stage 4.doc Version 1.40 Page 9 L’Arche places emphasis on providing staff with communication support skills and provides staff with Signalong training, and specialist training for communicating with adults with a learning disability. A database of photographs of all community members (core members and staff), significant locations and other useful objects is being developed to assist with this. Contracts of service between the service user and the home were not in place. (See requirement 2). Gothic Lodge G52-G02 S22732 Gothic V236768 040705 Stage 4.doc Version 1.40 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 standard(s) 6, 7, 8, 9 & 10 Service users needs are reflected in their individual plans. Service users are able to make decisions about their day to day lives, and are consulted on the running of the home and wider L’Arche community. They would benefit from the services of fully independent advocates. EVIDENCE: Individual care plans are reviewed annually and every six months new goals are reviewed/set with the individual, home staff and staff from the workshops. L’Arche are developing accessible service user plans. The four individual care plans examined were appropriate and detailed. Care records available indicated that steps are taken to meet the individual goals and care needs identified. One service user spoke about the weekly cooking sessions that staff supported him with and how he enjoyed a regular social activity with a member of the L’Arche workshop staff. Both were elements of his most recent care plan. Placing authorities had recently reviewed the care provided to the two service users whose files were examined. The service user, along with family members (if the service user wished) and home staff attend the annual review. Home staff work creatively with the service user before an annual review to enable them to understand and contribute as much as possible to the process Gothic Lodge G52-G02 S22732 Gothic V236768 040705 Stage 4.doc Version 1.40 Page 11 in ways of their individual choosing (video, photographs, spoken word, objects, music and drawings). The actual review meeting is held in a place that is comfortable to the service user (either at home or in a formal meeting room). The meeting aims to review goals from previous planning meetings and explore how new goals can be supported. The home has close links to the Lambeth community team for adults with a learning disability, who provide behaviour support and speech and language therapy as the need arises. A professional from the team spoke positively about the way home staff worked with the service users. L’Arche aims to provide each service user with a ‘reference person’ in the home to act as a keyworker. Fully independent advocates are in short supply in the borough. Although some service users have independant advocates, L’Arche uses a semi-independent advocacy system, with assistants from other homes or workshops who know the service user well, for service users without fully independant advocates. This is not ideal, but does ensure that someone from outside the home who knows the service user and sees them often is involved. A recommendation is made for L’Arche to pursue the services of fully independent advocates. (See recommendation 1). Each service user had a range of risk assesments on file. These risks had not been reviewed for over a year. Risks and actions taken to minimise them must be reviewed frequently, or as needs change, to ensure that service users independent skills development is not impeded and also to ensure that new risks are assessed and action is taken to minimise any potential hazards. (See requirement 3). 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. A fixed agenda had been devised for the weekly house meetings. The agenda items had been symbolised to assist service users to understand the format of the meeting. Confidential information was stored securely in the staff office. Gothic Lodge G52-G02 S22732 Gothic V236768 040705 Stage 4.doc Version 1.40 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 standard(s) 11, 12, 13, 14, 15, 16 & 17. Service users have opportunities for personal development. They are able to take part in a wide range of leisure activities and therapeutic employment. Appropriate relationships with family and friends are encouraged and supported. Service users are encouraged to be responsible in their daily lives. EVIDENCE: L’Arche is a faith based community and 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 L’Arche workshops (weaving, stone work, gardening and candlemaking), one attends a local authority day centre. Service users commented that they enjoyed their daytime activities. The proximity of the other L’Arche homes provides a close community. Service users regularly had supper invitations with friends living in other L’Arche Gothic Lodge G52-G02 S22732 Gothic V236768 040705 Stage 4.doc Version 1.40 Page 13 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 service users, with the intention of building a shared community and consistant 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. A televison and videos were available. The television is stored in a separate storage area and is brought into the communal area a few times a week. One service user said that he enjoyed television. It is recommended that the arrangements to access television is reviewed to ensure that the house routine does not impinge on the rights of an individual to enjoy the ‘in house’ leisure facilities of their choice. (See recommendation 2). Personal information held in individual care files contained detailed information about family and friends, their birthdays and family history. This enabled staff to support service users to maintain and develop family relationships. One service user spoke about regular visits to see a parent. Observed interactions between the staff and the service users were respectful, natural and caring. The service users and assistants eat at a large dining table together in the communal dining room. Service users and staff interacted well. A new member of staff was preparing the evening meal. Ingredients were fresh and she was using a cookbook made by one of the Gothic Lodge service users and a member of staff. The cookbook gave recipes and good colour photographs of favourite dishes. Records of meals eaten examined indicated that a range of meals had been served. Food stocks were stored appropriately and contained plenty of fresh fruit and vegetables. Each service user chooses and helps to prepare an evening meal each week to the best of their ability. One service user commented that he liked the meals. Gothic Lodge G52-G02 S22732 Gothic V236768 040705 Stage 4.doc Version 1.40 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 standard(s) 18, 19 & 20. The health needs of service users are well met with evidence of good multidisciplinary working taking place on a regular basis. The home has made good progress with regard to the arrangements for administration of medication. Three out of four previous requirements have been met. EVIDENCE: Service users were well dressed, in styles that reflected their personal choice and personality. Same gender personal care support is provided by a staff team comprised of both men and women. Personal care routines were clearly layed out in individual plans, detailing the level of support required with each task. There was evidence that the home manager had arranged a multi-disciplinary meeting in the ‘best interests’ of one of the service users who had needed a general anaesthetic for essential dental treatment. Gothic Lodge G52-G02 S22732 Gothic V236768 040705 Stage 4.doc Version 1.40 Page 15 One service user was reluctant to attend some healthcare appointments. These decisions had been recorded and the home manager spoke about the strategies that were being considered to ensure that he was making an informed choice. A best interests meeting would be convened if these strategies failed. A previous requirement to provide adequate and secure storage for medication has been met, and no gaps in recording were observed for the current and previous months Medication Administration Record (MAR) charts which was good evidence of improvement. No residents self-administer their medication. Both members of staff who administer have now received medication training. Any new members of staff who handle/administer medication must also receive formal training, as inhouse training is not usually of a sufficient standard. Training must include both of the following aspects: • • Basic knowledge of how medicines are used and how to recognise/deal with problems in use The principles behind all aspects of the homes policy on medicines handling and records A signature sheet has been put in place for staff who administer medication. No staff should administer medication unless they have had formal training. Staff must use the specified codes on MAR charts for any non-administration, and a list of these codes must always appear on the MAR chart template. The manager has implemented weekly stock counts. These must be expanded to enable a stock audit trail, so that the quantities of medication received, minus what has been used tallies with what has been returned. This is necessary to identify recording errors and possible misuse. (see Requirement 16). Receipts and returns are recorded in a separate log. Not all items have been logged. This must be done in order to provide a stock audit trail. (see Requirement 16). Medication is dispensed in weekly dossette boxes by staff. The home should not need to re-dispense into dossette boxes, unless this is being done to support residents to take their own medication. However this process is controlled and documented, including a check by a second member of staff on the quantities and medication identity, which is good practice. There is a medication profile available, which lists each resident, what they have been prescribed, what each medication is used for. This must be updated for all residents to include potential side effects in order to effectively monitor Gothic Lodge G52-G02 S22732 Gothic V236768 040705 Stage 4.doc Version 1.40 Page 16 any changes in condition of a resident which may be due to medication and should include when required “PRN” medication also (see Requirement 17). 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, but is in process. The Manager has confirmed that the GP is willing to approve a list of the homely remedies kept. This requirement is carried forward. (see Requirement 15). Laxative guidelines are available for 2 residents, which is good practice. Comments on the L’Arche medication policy have been supplied separately. Gothic Lodge G52-G02 S22732 Gothic V236768 040705 Stage 4.doc Version 1.40 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 standard(s) 22 & 23. There is a satisfactory complaints system with some evidence that service users feel that their views are listened to and acted upon. Service users are proteced from abuse, neglect and self harm. EVIDENCE: The home has 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 offered service users the opportunity to raise concerns. The home has revised the ‘visitors’ policy to provide service users with a suitable level of protection from abuse, as required in the previous inspection report. Overnight guests of staff must now be’ police checked’ in addition to being invited with the express permision of the service users. A record of visitors was available and was being used appropriately. Abuse awareness training is part of the L’Arche induction and formation training undertaken by all new staff. A spot check of service user finances held in safe keeping by staff indicated that adequate systems were in place to protect service users from financial abuse. Gothic Lodge G52-G02 S22732 Gothic V236768 040705 Stage 4.doc Version 1.40 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 standard(s) 24, 25, 26, 27, 28, 29 & 30. Recent investment has significantly improved the appearance of this home creating a comfortable environment for those living there and visiting. Environmental safety must be improved to ensure that service users, staff and visitors are adequately protected. EVIDENCE: The home is a large spacious old gothic style house with many original features and is in keeping with other homes in the area. It is a house that is comfortable and welcoming and is reasonably well maintained. The home accommodates a service user who uses a wheelchair. Level access and bathroom aids and adaptations are in place. There is also level access to all communal areas of the home, which are situated on the ground floor, including access to the garden. The upkeep of the home requires continual maintenance to maintain it in a good state of repair. The hallway, dining room and sitting room had been decorated recently and new lounge furniture and dining room curtains purchased. Gothic Lodge G52-G02 S22732 Gothic V236768 040705 Stage 4.doc Version 1.40 Page 19 All bedrooms are single occupancy, well furnished and personalised. A profiling bed with a window view is available for a service user with a mobility need. Dustbins previously obscuring the view from this window had been removed to reveal a pleasant view of the gardens. A bedside light had also been fitted. One service user commented that he liked his bedroom and was pleased that staff helped him to care for the pet goldfish in his bedroom by cleaning out the fish tank. The home was clean and satisfactory arrangements are in place for the disposal and handling of clinical waste. The home benefits from having a large pantry close to the kitchen. The home manager explained that there had been a small infestation of flying ants during recent hot weather. The majority of dry food provisions were stored in air tight containers, although not all. This is recommended. (See recommendation 3). Environmental health inspectors had visited the home in May 2005 to look at food preparation areas. They had made a number of recommendations that had been addressed by the home manager immediately. A missing kitchen light fiting above the food prepartion area was still missing and a pest control contract was not in place. These are required. (see requirements 4 & 5). An environmental health and safety risk assessment was in place but required updating as it had not been reviewed for a year. (See requirement 6). Fire authorities had visited the premises in July 2004 and made a number of requirements. Two ground floor fire doors needed attention to ensure that they closed effectively and fitted into the door frames properly (there was a gap at the base of each door). (See requirement 7). The first floor bathroom used by females in the home does not have any ventilation. This had been the subject of a previous requirement that is not met. (See requirement 8). The first floor mens bathroom had a broken ceiling light fitting. A repair or replacement is required. (See requirement 9). Gothic Lodge G52-G02 S22732 Gothic V236768 040705 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34 & 35. The arrangements for the induction of staff are good with staff demonstrating a clear understanding of their roles. Recruitment procedures have improved but still do not provide service users with adequate protection. The staff morale in this home is low as a result of a high turnover of staff. This situation is having a detrimental impact on the standard and consistency of care offered within this home. 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 be duty. L’Arche is a Christian community, that requires staff to be part of all aspects of care and support and a committed community lifestyle. Staff are paid a small wage/expenses for a 40 hour week commitment to the home and L’Arche community. L’Arche assistants are volunteers, usually from abroad, who work in the homes for one or two years. A L’Arche framework of policies and procedures, provides staff with guidance. There had also been ongoing staff support and training from the home manager, the homes co-ordinator and other long standing community staff. The status of the assistants means that they normally do not have NVQ qualifications and the director of L’Arche has Gothic Lodge G52-G02 S22732 Gothic V236768 040705 Stage 4.doc Version 1.40 Page 21 conceded that it will be hard for the organisation to meet this standard by 2005. (See requirement 10). There has been a high turnover of staff, which has been unsettling for service users at times (one service user has attachment disorder). Professionals consulted also raised concerns about the frequent staff team changes. L’Arche should look at how staff retention can be improved. (See recommendation 4). The home manager and a staff member had been working an excessive number of hours as the home was short of staff. This is unsatisfactory. A requirement is made for staffing levels to be reviewed and an adequate number of relief staff deployed to ensure safe working time is not exceeded. (See requirement 12). Recruitment records are held at the L’Arche head office. A recruitment coordinator has made progress in auditing staff recruitment records, although the records are still incomplete in some cases. References taken up by telephone had not been authenticated in writing, and documents confirming the identity of individual staff, including recent photographs, were not in place. This does not provide service users with adequate protection and was the subject of a requirement in the previous inspection report that is not met. (See requirement 11). Training records are held at the L’Arche head office. A training co-ordinator has made progress with compiling a team training and development needs assessment for each of the L’Arche homes and individual records of training undertaken by each member of staff. 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. NVQ training is provided for staff who are able to commit to more than two years. Working visa constraints prevent some staff from staying for more than a year so few have achieved this. Gothic Lodge G52-G02 S22732 Gothic V236768 040705 Stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 40, 42 & 43. The home regularly reviews aspects of its performance through a programme of self-review and consultations, which includes seeking the views of service users, staff and relatives. The manager is registered and competent but must undertake appropriate training to fully develop her care and management skills. The management of health and safety precautions must be better developed to ensure that service users are protected. EVIDENCE: The registered home manager has been in post for a year and has undertaken to begin an NVQ level 4 in Care and Registered Managers Award this year. (See requirement 13). The L’Arche community has an annual development plan for quality assurance in place. The home is visited on a monthly basis by a representative of the responsible individual as required by Regulation 26 of The Care Homes Gothic Lodge G52-G02 S22732 Gothic V236768 040705 Stage 4.doc Version 1.40 Page 23 Regulations 2001. Reports on the findings of these regular inspections are maintained in the home and supplied to the CSCI. The L’Arche policies and procedures are reviewed periodically and a number have been reviewed or developed in 2004, including physical restraint, challenging behaviour, risk assessment, internal incident reporting, internal financial controls, confidentiality, medication, visitors and transport. L’Arche has demonstrated that policy and procedure are reviewed in light of changing circumstances. The Annual Landlords Gas Boiler safety certificate was issued on 13/12/04. Mains electric circuitry had been safety checked on 05/07/02. The test certificate was noted to cover a five-year period from that date. Small electrical appliances had been safety tested by a trained house assistant. A record had been made of the items tested by the assistant on 4th March 2005. Fire authorities had inspected the premises on 14/07/04. (See requirement 7). Regular checks had been conducted on fire detection and emergency equipment. Fire drills and evacuation procedures had been conducted and the outcome of the evacuations recorded. Issues of both personal and premises security had been considered and addressed. Accidents, incidents, injuries and illnesses had been recorded appropriately. ‘In house’ Health and safety responsibilities were nominated and records of checks maintained. An environmental risk assessment was in need of review. (See requirement 6). COSHH (Control of Substances Hazardous to Health) information sheets were available, although cleaning products and other liquids (nail varnish remover) were available in areas of the home and this presents a safety hazard. (See requirement 14). The inspector noted that a fire risk assessment and building floor plan were available. Thermostatic hot water safety control mechanisms had been fitted to hot water outlets to prevent scalding. Window opening restrictors had been fitted to prevent falls. Gothic Lodge G52-G02 S22732 Gothic V236768 040705 Stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 3 3 2 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 3 3 2 Standard No 11 12 13 14 15 16 17 3 3 2 2 2 3 3 Standard No 31 32 33 34 35 36 Score x 2 2 2 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Gothic Lodge Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 2 x 3 3 x 2 3 G52-G02 S22732 Gothic V236768 040705 Stage 4.doc Version 1.40 Page 25 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 4(1)(c) & Sch 1 Requirement The registered persons must ensure that the staffing information in the Statement of Purpose is reviewed and revised to include current staffing. The registered persons must ensure that service contracts are in place for each service user. The registered persons must ensure that risks posed to individual service users are reviewed regularly and when needs change. The registered persons must repair/replace the light fitting above the food preparation area (as advised by Environmental Health Inspectors). The registered persons must ensure that the home is professionaly checked for pest and rodent infestation on a regular basis. The registered persons must review the environmental health and safety risk assessment on a regular basis. The registered persons must confirm that action has been taken to rectify the areas of concern identified by the LFCDA Timescale for action 28 October 2005 2. 3. YA5 YA9 5(3) & 12(5)(a) 14(2)(a) & 13(4)(b) 16(2)(j) & 23(2)(b) 28 October 2005 30 September 2005 30 September 2005 30 September 2005 29 October 2005 30 September 2005 Page 26 4. YA24 5. YA24 13(3) & 13(4)(a) 6. YA24 23(2)(b) & 13(4)(a) 23(4)(a) 7. YA24 &YA42 Gothic Lodge G52-G02 S22732 Gothic V236768 040705 Stage 4.doc Version 1.40 8. YA27 23(2)(p) 9. YA27 23(2)(b) 10. YA32 18(1) 11. YA34 19(1) & Sch 2 12. YA33 18(1)(a) Fire Authorities most recent inspection report (carried out on 14/07/04). Two ground floor fire doors must be altered to ensure effective closure and close fitting to the floor. Previous requirement of 20/05/05 not met. The registered persons must ensure that the first floor bathroom designated for use by female service users is adequately ventilated. Previous requirement of 29/07/05. The registered persons must ensure that the ceiling light fitting in the mens first floor bathroom is repaired or replaced. The registered persons must ensure that 50 of care staff hold an NVQ 2 or 3 or are working to achieve one by an agreed date;or the registered manager can demonstrate that through past work experience staff meet this standard. New guidance has been issued by the CSCI in regard to this standard. The registered persons must ensure that evidence of all information and documentation required by Schedule 2 of the Care Homes Regulations 2001 (revised in July 2004) is obtained for staff before they commence work in the care home. The revised recruitment procedure must be sent to the CSCI Southwark office. Previous requirement of 30/06/05 not met. The registered persons must ensure that at all times suitably qualified, competent and experienced persons are working 29 July 2005 31 August 2005 31 December 2005 31 August 2005 19 August 2005 Gothic Lodge G52-G02 S22732 Gothic V236768 040705 Stage 4.doc Version 1.40 Page 27 13. YA37 9 14. YA42 13(4)(c) 15. YA20 13(2) 16. YA20 13(2) 17. YA20 13(2) in the home in such numbers as are appropriate for the health and welfare of the service users. Staffing levels must be reviewed and individual staff must have an adequate number of rest days in line with working time regulation. Newly proposed staffing levels must be supplied to the CSCI Southwark office. The registered persons must ensure that the registered home manager undertakes the required NVQ level 4 qualification in both care and management. The registered persons must ensure that the practice of storing cleaning materials/prescribed topical products in bathrooms is risk assessed to ensure that adequate steps are taken to maintain the safety of service users. 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. The registered persons must ensure that all receipts and returns of medication are logged, and regular stock checks conducted and evidenced to provide a complete stock audit trail for prescribed items. The registered persons must ensure medication profiles are updated for all service users to include potential side effects in order to effectively monitor any changes in condition of a resident which may be due to 31 December 2005 31 August 2005 30 September 2005 30 September 2005 30 September 2005 Gothic Lodge G52-G02 S22732 Gothic V236768 040705 Stage 4.doc Version 1.40 Page 28 medication and should include when required “PRN” medication also. 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 YA7 YA14 YA30 YA33 Good Practice Recommendations The registered persons should pursue independant advocacy services for LArche service users. The registered person should review the practice of restricting access to the communal television. The registered persons should store all dry food provisions in air tight containers. The registered persons should look at ways in which staff retention can be improved. Gothic Lodge G52-G02 S22732 Gothic V236768 040705 Stage 4.doc Version 1.40 Page 29 Commission for Social Care Inspection SE London Area Office Ground Floor, 46 Loman Street Southwark London 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 G52-G02 S22732 Gothic V236768 040705 Stage 4.doc Version 1.40 Page 30 - 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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