Inspection on 06/12/05 for Gothic Lodge

This inspection was carried out on 6th December 2005.

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 22 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 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 6th December 2005 08:30 Gothic Lodge DS0000022732.V266229.R01.S.doc Version 5.0 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.V266229.R01.S.doc Version 5.0 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.V266229.R01.S.doc Version 5.0 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.V266229.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th July 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 and high street shopping. 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. Gothic Lodge DS0000022732.V266229.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection of Gothic Lodge was unannounced and took place over four hours. It consisted of talking with four service users, the home manager and a member of staff. Records of care provided were examined and there was a tour of all communal areas and the five bedrooms occupied by service users. Staff recruitment records were examined at the LArche head office on 16 November 2005. What the service does well: What has improved since the last inspection? Carpets have been steam cleaned and all service users have new mattresses. Information in the statement of Purpose and service users’ guide has been updated to include information about new staff. Gothic Lodge DS0000022732.V266229.R01.S.doc Version 5.0 Page 6 Lighting has improved in the kitchen and ventilation and lighting has been repaired in the bathrooms. 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.V266229.R01.S.doc Version 5.0 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.V266229.R01.S.doc Version 5.0 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&5 Prospective service users have adequate information to make an informed decision to move to Gothic Lodge. Service users do not have contracts detailing their terms and conditions with the home. This is not indicative of a professional relationship. EVIDENCE: The home has an informative ‘Statement of Purpose’ and ‘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. Contracts of service between the service user and the home are not in place. (See requirement 1). Gothic Lodge DS0000022732.V266229.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 Risks are not reviewed often enough and there is a need for overall risk assessment. EVIDENCE: Each service user had a range of risk assessments on file. These risks have not been reviewed for over a year. As staff live on premises and do not have bedroom door locks, there is a need assess the risks posed by items/medications that they more store in their bedrooms for personal use and to take remedial action as necessary. 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 taken to minimise any potential hazards. (See requirement 2). Risk assessments available address known risk areas. There is no overall risk assessment audit tool to enable staff to examined risks in all areas of daily living and activity. This is recommended. (See recommendation 1) Gothic Lodge DS0000022732.V266229.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14 & 15 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. 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. 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 Gothic Lodge DS0000022732.V266229.R01.S.doc Version 5.0 Page 11 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. 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. Observed interactions between staff and service users were respectful, natural and caring. The service users and staff eat together at a large dining table in the communal dining room. Gothic Lodge DS0000022732.V266229.R01.S.doc Version 5.0 Page 12 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): 20 Service users need assistance with their medication. Staff are not trained appropriately and record keeping does not provide service with adequate protection. EVIDENCE: All service users require staff support to take their medication. All medication is stored securely and administered by staff. The CSCI pharmacist made a number of requirements about the handling of medicines in the previous inspection report. Progress with meeting these requirements was examined, as were MAR charts and stock. As there has been a high staff turnover, the only member of staff to have completed training in medication is the home manager. 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 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 DS0000022732.V266229.R01.S.doc Version 5.0 Page 13 Gothic Lodge No staff should administer medication unless they have had formal training. (See requirement 3) 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 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. Not all items have been logged. This must be done in order to provide a stock audit trail. (See requirement 4). 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 service user 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 service user, 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 service user has not yet been met. (See requirement 5). MAR charts have been hand written on occasion. These records are not clear. When an additional medication is prescribed, and there is no room on the existing MAR chart, an additional pre-printed record should be introduced. (See requirement 6) The record of administration for three courses of antibiotics did not tally with the number of tablets prescribed and received by the home. MAR charts suggest that medication administered by workshop staff (lunchtime doses) had not been signed for on occasion. This must be addressed and workshop staff must be included in staff training if they are administering medication. (See requirement 3) One service user had been prescribed medication whilst on holiday in France. There is no record of what was prescribed or of administration. (See requirement 6) Gothic Lodge DS0000022732.V266229.R01.S.doc Version 5.0 Page 14 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 Service users views are listened to and acted upon but the records of complaints investigation is not sufficiently detailed. 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 offer service users the opportunity to raise concerns. One complaint is recorded since the last inspection visit. A service user complained that the heating was not working properly. Although the heating system has been repaired the complaints record is not sufficiently detailed and does not include the timescales and actions taken. (See requirement 7) Gothic Lodge DS0000022732.V266229.R01.S.doc Version 5.0 Page 15 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 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 needs. Shared spaces complement and supplement individual rooms and service users have the specialist equipment they require to maximise their independence. However, there are a number of areas that pose risks to the safety of service users and staff. EVIDENCE: The home is a large, gothic style house with many original features. It is in keeping with other homes in the area. It is comfortable and welcoming and reasonably well maintained. 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. 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 radiators in this service users bedroom should be covered to prevent contact burns. (See requirement 8) Gothic Lodge DS0000022732.V266229.R01.S.doc Version 5.0 Page 16 Carpets have been steam cleaned since the last inspection visit and all service users have new mattresses on their beds. 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 2) Fire authorities visited the premises in July 2004 and made a number of requirements. Two ground floor fire doors need attention to ensure that they close effectively and fit into the doorframes properly (there is a gap at the base of each door). These doors are still not closing effectively. (See requirement 9). A large number of fire doors are routinely wedged open. (See requirement 10) Ground floor hallway lighting is not working. (See requirement 11) Gothic Lodge DS0000022732.V266229.R01.S.doc Version 5.0 Page 17 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. Staff roles and responsibilities are clear, although there are an insufficient number of staff available. Staffing levels must be reviewed and increased to ensure that staff do not work excessive hours. Recruitment procedures have improved but still do not provide service users with adequate protection. Staff training has improved, but high staff turnover has reduced the effectiveness of the training plan. Staff are supervised regularly. 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. A L’Arche framework of policies and procedures provides staff with guidance and there is ongoing staff support and training from the home manager, the homes co-ordinator and other long standing community staff. As assistants usually only stay for between one and three years, the director of L’Arche has conceded that it will be hard for the organisation to meet the standard in regard to NVQ qualifications by 2005. (See requirement 12) Gothic Lodge DS0000022732.V266229.R01.S.doc Version 5.0 Page 18 There is a training programme for staff working at Gothic Lodge. Training is obtained from the local community team for adults with a learning disability who operate a rolling programme for local care providers and also the LArche foundation-training programme. A number of new staff have recently arrived at Gothic Lodge. There is a high turnover of staff, which is unsettling for service users. Staff are also working long hours with insufficient rest time. L’Arche has looked at ways to improve staff retention and a new system of working is planned for 2006. This will reduce the number of hours worked by each member of staff and will require an increase in staffing levels. Staffing levels must therefore be reviewed. (See requirement 13) Staff duty rotas are in place and show that a sufficient number of staff are on duty at all times. Staff duty records are not sufficiently detailed and do not include the full names of staff working in the home. (See requirement 14) Additional staff cover is provided by other LArche community staff if needed. Recruitment records are held at the L’Arche head office. A recruitment coordinator has made progress in auditing staff recruitment records and is currently revising the LArche recruitment procedures. The records are still incomplete in some cases. References taken up by telephone are not all authenticated in writing. Recruitment practice is such that some staff arrive in the UK, and move into the Gothic Lodge, before a satisfactory POVA first check and enhanced CRB check are obtained. At the time that recruitment records were checked (16 November 2005) twelve members of staff (working both at Gothic Lodge and elsewhere in the LArche community) did not have UK CRB checks in place or confirmation of a satisfactory POVA First check. Overseas police checks are obtained before staff arrive in the UK and all have since applied for an enhanced UK CRB check and POVA First check. This is not in accordance with vetting procedures for the protection of vulnerable adults. (See requirement 15) 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 he felt supported and had adequate opportunity to discuss any concerns and contribute ideas. Gothic Lodge DS0000022732.V266229.R01.S.doc Version 5.0 Page 19 Supervision meetings are held regularly but a record is not always kept. Supervisees should be given a copy of their supervision notes. LArche also provides each member of staff with a member of the community fro outside of their home base to provide additional support. (See recommendation 3) Gothic Lodge DS0000022732.V266229.R01.S.doc Version 5.0 Page 20 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 & 42. The home manager is competent and staff appreciate her leadership and management approach. The registered provider has failed to monitor the home with the required regularity. 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. A member of staff said that her management style was inclusive, supportive and positive. The L’Arche community has an annual development plan for quality assurance in place. 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 16) Gothic Lodge DS0000022732.V266229.R01.S.doc Version 5.0 Page 21 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 9). A fire risk assessment and building floor plan are available. Thermostatic hot water safety control mechanisms are fitted to hot water outlets to prevent scalding. Window opening restrictors are fitted to prevent falls. A number of requirements have been made in regard to health and safety in other areas of this report. (See requirements 2, 8, 10 & 11) Gothic Lodge DS0000022732.V266229.R01.S.doc Version 5.0 Page 22 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 3 X X X 2 Standard No 22 23 Score 2 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 2 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score 3 2 2 2 2 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Gothic Lodge Score X X 2 X Standard No 37 38 39 40 41 42 43 Score 2 3 2 X X 2 X DS0000022732.V266229.R01.S.doc Version 5.0 Page 23 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 YA5 Regulation 5(3) 12(5)(a) Requirement The registered persons must ensure that service contracts are in place for each service user. Previous timescale of 28/10/05 not met. The registered persons must ensure that risks posed to individual service users are reviewed regularly and when needs change. Risk assessment review must include missing persons and risks posed to service users by items stored in unlocked staff bedrooms. Previous timescale of 30/09/05 not met. The registered person must ensure that all staff administering medication are adequately trained (this must include workshop staff if necessary). The registered persons must ensure that all receipts and returns of medication are logged to provide a complete stock audit trail for prescribed items. The registered persons must ensure that advice is sought DS0000022732.V266229.R01.S.doc Timescale for action 03/03/06 2 YA42YA9 14(2)(a) 13(4)(b) 03/02/06 3 YA20 13(2) 18(1) 03/03/06 4 YA20 13(2) 03/02/06 5 YA20 13(2) 03/03/06 Gothic Lodge Version 5.0 Page 24 6 YA20 13(2) 17(1)(a) 7 YA22 17(2) Sch 4(11) 8 YA42YA26 12(1) 13(2) 23(2) 9 YA42YA24 23(4)(a) 10 11 12 YA42YA24 YA42YA24 YA35YA32 23(4) 12(1) 23(2) 12(1) 18(1) 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 timescale of 30/09/05 not met. The registered person must ensure that there is an accuate and clear record of any medication prescribed and/or administered. The registered persons must maintain a detailed record of complaints made, action taken as a result, timescales and whether the complaint was substantiated or not. The registered person must take action to prevent contact burns from radiators in areas accessible to a service user with mobility needs (note: positioning of mobility aids to block access is not sufficient). The registered persons must confirm that action has been taken to rectify the areas of concern identified by the LFCDA 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 & 30/09/05 not met. The registered persons must ensure that fire doors are not wedged open. The regsitered person must ensure that ground floor hallway lighting is functional. The registered persons must ensure that 50 of care staff DS0000022732.V266229.R01.S.doc 03/02/06 03/02/06 03/02/06 03/02/06 30/12/05 30/12/05 03/02/06 Gothic Lodge Version 5.0 Page 25 13 YA33 18(1)(a) 14 YA33 17(2) Sch 4(7) 15 YA34 19(1) Sch 2 16 YA39 26 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 at all times suitably qualified, competent and experienced persons are working 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. Previous requirement of 19/08/05 not met. The registered person must ensure that staff duty rotas identify the names of each member of staff working in the home each day. 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 31/08/05 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. DS0000022732.V266229.R01.S.doc 03/03/06 30/12/05 30/12/05 30/12/05 Gothic Lodge Version 5.0 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA9 YA30YA24 YA36 Good Practice Recommendations The registered persons should develop an overall risk assessment audit tool. The registered person should have a pest control contract. The registered manager should implement a system for staff supervision meetings that records action points and timescales. Both the supervisor and the person being supervised should sign the notes and both parties should retain a copy. Gothic Lodge DS0000022732.V266229.R01.S.doc Version 5.0 Page 27 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.V266229.R01.S.doc Version 5.0 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!