Inspection on 08/12/08 for Gothic Lodge

This inspection was carried out on 8th December 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 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 12/02/08

Gothic Lodge 21/04/06

Gothic Lodge 06/12/05

Gothic Lodge 04/07/05

Gothic Lodge 07/03/05

Gothic Lodge 03/09/04

Gothic Lodge 24/03/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 08/06/2011.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Gothic Lodge 21 Idmiston Road West Norwood London SE27 9HG The quality rating for this care home is: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Sonia McKay Date: 0 8 1 2 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area Outcome area (for example: Choice of home) These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Reader Information Document Purpose Author Inspection report CSCI Page 2 of 32 Care Homes for Adults (18-65 years) Audience Further copies from Copyright General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 32 Information about the care home Name of care home: Address: Gothic Lodge 21 Idmiston Road West Norwood London SE27 9HG 02087618044 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): gothiclodge@yahoo.co.uk L`Arche Lambeth Name of registered manager (if applicable) Miroslawa Wasiuk-Wojcik Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 Over 65 6 6 0 0 care home 6 learning disability physical disability Additional conditions: Date of last inspection Care Homes for Adults (18-65 years) Page 4 of 32 A bit about the care home 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 LArche Lambeth, an Ecumenical Christian Community that welcomes people of all faiths and people of no stated faith. Strong emphasis is placed on the `community? of staff and service users. Prospective service users receive an information pack about the service and a copy of the most recent Commission inspection report is available on request at the home. Current fees range between £433.60 and £517.39 per week and depend on the support needs of individuals placed. Care Homes for Adults (18-65 years) Page 5 of 32 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home Care Homes for Adults (18-65 years) Page 6 of 32 How we did our inspection: This is what the inspector did when they were at the care home The last key inspection of this service was carried out on the 12th February 2008. This key inspection was carried out by one inspector over two days and involved a review of the information supplied to us by the registered provider, talking with residents and staff and looking at records kept in the home. There was also a tour of the communal areas of the home and some of the bedrooms. Residents and staff also completed surveys. What the care home does well Prospective residents are given time to experience life in the home before they decide whether they want to move in. Residents are asked about what they want to do and how they want to be cared for and staff use pictures and other aids to help people make choices. There is a good range of things to do in the daytime and in the evening and there is a community spirit with residents living in other homes in the area. People can learn new skills and take part in employment in the LArche workshops. The home is comfortable and clean and there is a large garden. Care Homes for Adults (18-65 years) Page 7 of 32 What has got better from the last inspection What the care home could do better There must be better assessment of risk. This means that staff have to think about and write down any places or activities that may cause someone harm. This must be done so that people are kept as safe as possible and are also able to take risks. Staff must write down how each person needs to be cared for and supported. These written plans must cover all areas of health and social care and they must be reviewed regularly so that staff know what to do. Care Homes for Adults (18-65 years) Page 8 of 32 Staff must write down a list of all of the things that they are looking after for residents to keep them safe. Staff must do more to ensure that they are giving medicines safely. The staff team and manager of this service have changed frequently and this does not provide good continuity of care. Residents have to get to know new staff often. The home needs a qualified and experienced manager to provide leadership and support. If you want to read the full report of our inspection please ask the person in charge of the care home If you want to speak to the inspector please contact Sonia McKay 33 Greycoat Street London Care Homes for Adults (18-65 years) Page 9 of 32 SW1P 2QF 02079792000 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line - 0870 240 7535 Care Homes for Adults (18-65 years) Page 10 of 32 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 11 of 32 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Care has been taken to make sure that prospective residents have accessible information about the home and opportunity to experience life in the home before they make a decision to move in for a trial period. Evidence: There is an informative Statement of Purpose and a Service Users Guide. Emphasis is placed on making the guide accessible to people who have a learning disability and it contains many colour photographs, symbols and clear language. This makes it easier to understand. Additional information about placement fees and how they are spent has been included in the residents guide and each resident now has a pictorial version of their placement contract which contains information about individual fee levels. There are plans to further review and improve the contracts to ensure that they are an effective method of communicating information about money. Currently all residents are funded by a placing authority and there are no privately funded places. There have been no admissions to the home since the last inspection visit. Residents are admitted on the basis of a full assessment of needs. The registered provider obtains copies of the care needs assessments carried out by health and social services Care Homes for Adults (18-65 years) Page 12 of 32 Evidence: as part of the referral process. Only long term placements are offered and there is a lengthy placement process. This is tailored to meet the needs of the individual and usually involves at least two brief visits to the home and three longer visits, including overnight stays. This provides the prospective resident with ample opportunity to experience life in the home before making a decision to move in for a trial period. At previous inspections it has been noted that the ethnic mix of the staff team is not reflective of the mix of the residents. This presents a challenge for the team in understanding and meeting the cultural needs of the residents. The provider plans to try and address this by recruiting a wider mix of staff in future. This will be of benefit to some residents. Care Homes for Adults (18-65 years) Page 13 of 32 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . More must be done to ensure that the assessed and changing needs and personal goals of each resident are accurately documented and regularly reviewed. Evidence: Staff maintain a variety of records and plans for each resident. These are stored in files in the staff office. There is no standard template for how these plans are formulated or maintained, although the provider aims to have at least one full service review each year. The records and plans for two of the current residents were looked at during this inspection. There is some good information about life histories and family and friends and how these contacts are supported, but planning processes are fragmented and unclear. Each resident has three files of written information and current plans and risks assessments and management plans are not easily located. Some risks have been reassessed recently, but not all. There is some good information about preferred routines and elements of goal setting and steps are taken to ensure that the views and wishes of each resident are included and documented during review meetings. This is done by recording their comments Care Homes for Adults (18-65 years) Page 14 of 32 Evidence: and by involving semi-independent advocates (community staff who know the person well) and family and friends as appropriate. Copies of review notes have been sent to placing authorities, but local authority statutory annual placement reviews are overdue in some cases. Care Homes for Adults (18-65 years) Page 15 of 32 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Residents are able to take part in a wide range of leisure activities and therapeutic employment. Relationships with family and Friends are encouraged and supported. Residents are offered a healthy diet and mealtimes are sociable occasions. Evidence: LArche is a faith based community that offers active support to each resident to enable them to develop their faith and spiritual lives. Residents who choose not to attend religious activities of any particular denomination are offered opportunities to engage in art, music and nature. Most of the current residents attend LArche workshops and groups for daytime activities. The close proximity of the other LArche homes provides a close community. Residents regularly have supper invitations to see friends living in other LArche homes in the area. LArche 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 Care Homes for Adults (18-65 years) Page 16 of 32 Evidence: engagement between the staff and residents. All residents are offered a minimum of two weeks of holiday away from the home in each year, either alone with staff support or as part of a group with shared interest. There is a range of in-house activities available, including television, dvds, music and musical instruments. Evening and weekend activities in the community and at home are also provided. Personal information held in individual care files contains detailed information about family and friends, their birthdays and family history. This enables staff to support residents to maintain and develop family relationships. Records of the meals prepared show that a range of meals is served. Food stocks are plentiful and include plenty of fresh fruit and vegetables. Dry goods stored in a pantry are now securely stored in air-tight containers as required during the last inspection. This helps to keep them free from pests. Each resident chooses and helps to prepare an evening meal to the best of their ability and staff and residents eat main meals together at a large dining table, often with friends. Residents also make snacks and drinks without support if they are able. Culturally appropriate meals feature more often on house menus. One resident enjoys an Italian cooking evening, and staff are becoming more familiar with Caribbean dishes prepared by family members for another resident. Care Homes for Adults (18-65 years) Page 17 of 32 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Staff provide adequate support with health and personal care issues. Planning and record keeping could be improved by more frequent review. The people who run the home must do more to monitor how safely medications are being handled and any errors must be properly investigated once identified. Evidence: Staff provide assistance to residents to select clothes that are appropriate to the weather and activities planned. A member of staff who is the same gender as the resident provides support with any personal care that is required. Personal care is provided in the privacy of bathrooms and bedrooms. Preferred bathing routines are written down describing the level of support required with each personal care task. As mentioned earlier in this report, there is a need to review this written information frequently to ensure that staff have up to date information about how to provide the correct amount of support to each resident. Some health action plans are in place, although there is a need for more frequent review and consolidation of information. Each resident is registered with a local Doctor. The staff support residents to make and attend health care appointments. Each persons care file has a detailed health information form to be given to medical staff in the event that a resident is taken to hospital in an emergency. This is good practise. Staff also keep records of what has Care Homes for Adults (18-65 years) Page 18 of 32 Evidence: happened at each appointment, including any medical advise given. The two sets of health records examined provide evidence that that general health care and individual health care needs are met and records are kept of the outcomes of each appointment. Lambeth specialist team for adults with a learning disability provides input on referral. Input can includes psychology, physiotherapy and speech and language therapy. All residents currently require staff support to take their medication, although there are plans to assist one resident to move to wards self-medication. All medication is stored securely and administered to residents by staff, who are trained in safe administration. There are no controlled drugs in stock. A member of staff had been conducting justified weekly medication stock counts to enable a stock audit trail. This is necessary to identify recording and administration errors or any possible misuse. There is evidence that on occasions when errors have been found no action has been taken to investigate them. This is unsafe. There are records of how much medication is received into the home and of how much is returned to the pharmacy. There is a medication profile available, which lists each resident, what they have been prescribed, what each medication is used for and any possible side effects. Advice has been taken about suitable over the counter remedies for common ailments such as coughs and colds. This advise should be reviewed when any new medications are prescribed and at any medication review. Most prescribed medication is supplied in blister packs filled by the pharmacist. All medication is in stock at the time of this inspection. Care Homes for Adults (18-65 years) Page 19 of 32 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . The views and concerns of residents are listened to and acted upon and there are good systems in place to handle complaints. Steps are taken to protect residents from abuse although financial safeguards must be improved to ensure adequate protection from financial abuse. Evidence: There is a good complaints policy. There is text version and a more accessible version for residents who may not be able to understand a text only document. A complaints poster is displayed on the notice board in a communal area and has colour photographs of people who can assist with a complaint, including the Commission. Regular house meetings provide residents with an opportunity to raise concerns. The home manager has arranged the complaints book so that the timescales of any complaints investigation are recorded. There have been no complaints since the last inspection visit. Abuse awareness training is part of the LArche induction and formation training undertaken by all new staff. An up to date copy of the Lambeth adult protection procedures are available for reference. All residents require assistance with financial matters. Receipts are retained for all transactions and stored with the individual expenditure records. These records are periodically audited by the LArche financial controller and are also part of the Regulation 26 monitoring inspections conducted on behalf of the registered provider. This provides residents with safety from financial abuse. A spot check of cash held in the safe keeping for two of the residents indicate that cash balances tallied with records in one case and in the other there was too much cash in the tin. Foreign currency and valuable documents, such as Care Homes for Adults (18-65 years) Page 20 of 32 Evidence: bank books, that are held in safe keeping are not recorded and individual financial arrangements are not well documented and should be developed into individual financial support plans and reviewed regularly along with all other elements of care and support planning. A record of visitors is available and is being used appropriately. Care Homes for Adults (18-65 years) Page 21 of 32 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Residents live in a comfortable and homely environment. More emphasis must be placed on ensuring that the home environment is maintained safely. 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 the first floor of the home. All bedrooms are single occupancy, well furnished and personalised. There is ongoing re-decoration and two bathrooms, the laundry room and one of the residents bedrooms have been re-decorated since the last inspection visit. A profiling bed with a window view is available in the ground floor bedroom of a resident with a mobility need. 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 large garden. The home is clean and satisfactory arrangements are in place for the disposal and handling of clinical waste, although there are no regular checks for pests or vermin being done. Automatic door closures, that shut automatically if the fire alarm goes off, are fitted to the fire doors in the ground floor hallway. This means they can be safely left open during the daytime to enable a resident who uses a wheelchair to move around the Care Homes for Adults (18-65 years) Page 22 of 32 Evidence: building more easily. Risks posed by having unguarded surfaces (such as central heating radiators) have not been formally assessed, and a requirement made in this regard has not been addressed. There must be full written assessment of the risks posed and any remedial action needed, such as fitting radiator covers or covering hot pipework. These risks must be reviewed regularly. There are several damaged areas of carpet on the first floor communal hallway floor. This is a trip hazard and the carpet must be repaired or the floor covering replaced. Care Homes for Adults (18-65 years) Page 23 of 32 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Continual high staff turnover means that there is limited progress in developing a qualified staff team and residents have to get to know knew staff often. This is not ideal and more should be done to ensure continuity of care and support. Evidence: In the LArche community of homes in the area, the care staff are called assistants. There are two or three assistants on duty each day and two assistants are appointed to be available, if needed, during the night (most assistants live on premises). There is no waking cover at night. There is currently an assistant vacancy and this shortfall is filled by LArche assistants from neighbouring homes in the LArche community or by agency carers. A record is kept of which assistants were on duty on each day. The LArche community also has a team of assistants who staff day services. These are based at workshops or shared interest groups. There is also a small team who focus on involving people in community based activities. There are currently three female assistants and two male assistants. None of the staff have attained a vocational qualification in care and there is high assistant turnover. Six assistants have left in the last twelve months. There is a staff training and induction programme in place staff and staff were given extra training in meeting the needs of a resident who is developing symptoms of dementia. High staff turnover means that residents have to share their home with, and get to know, new staff frequently. The turnover also reduces the impact of the training and development plan. Most staff are from overseas Care Homes for Adults (18-65 years) Page 24 of 32 Evidence: and visa restrictions mean that staff often leave after completing the first years foundation training. Records of review meetings seen, indicate that the high staff turnover also has an disruptive affect on the key working system. This is addressed, to some extent, by each resident having a reference group of people involved in their life planning meetings. These are friends and assistants from within the LArche community who know the resident well. Feedback from staff indicates that they have found the training valuable but they would have benefited from clearer information about daily routines with individual residents. One assistant considered out of date information in the files to led to gaps in essential knowledge about how each resident needs to be supported. The composition of the staff group does not reflect that of the residents. Staff recruitment records for two of the new assistants were examined and there is evidence that satisfactory checks have been made on their identity and background. This includes employment and personal references and checks against the list of people who should not work with vulnerable adults. All staff are subject to an enhanced check of their criminal records. Care Homes for Adults (18-65 years) Page 25 of 32 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . The service needs a manager to provide leadership and support to a relatively inexperienced and unqualified staff team. There is also a need to review fire safety arrangements to make sure that residents are as safe as possible in the event of a fire. Evidence: The post for registered home manager is vacant. The Commission recently registered a home manager but the manager left the service in December 2008 and is yet to be replaced. The area manager is currently providing interim management support until a new manager is appointed. There are regular monthly inspection visits conducted by representatives of the registered provider. During the last inspection there was concern that these visits were not conducted often enough. Copies of reports from recent inspections are maintained at the home and these indicate that the inspections are now happening each month, as required. This is a way for the registered provider to monitor the service being provided. Regular house and community meetings are held to ensure that residents are involved and consulted about the running of the community and planning home life. There is no defined quality assurance system in place and there is a need for wider consultation, for example surveying the views of all stakeholders. Care Homes for Adults (18-65 years) Page 26 of 32 Evidence: Staff conduct regular health and safety checks of the premises and record the outcomes. An environmental risk assessment is reviewed annually. Fire evacuation drills take place regularly but there is a need to review the fire evacuation procedures and fire risk assessment in light of the increasing needs of some of the residents, and to update the building floor plan. The Commission issues a certificate providing details of the type of service that the home is registered to provide. Only one page of the certificate is displayed in the home. Both pages of the certificate must be displayed. An Employers liability insurance certificate could not be located during the inspection, this must also be in place and displayed. Care Homes for Adults (18-65 years) Page 27 of 32 Are there any outstanding requirements from the last inspection? Yes  No  Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No Standard Regulation Requirement Timescale for action 1 9 13(4) The registered person must ensure that risks posed to residents are reviewed regularly and when their needs change. 03/04/2009 2 26 13(4) The registered persons must 03/04/2009 conduct an assessment of the risks posed by unguarded radiators in bedrooms. Care Homes for Adults (18-65 years) Page 28 of 32 Requirements and recommendations from this inspection Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No Standard Regulation Description Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set No Standard Regulation Description Timescale for action 1 6 15 Each resident must have clear written plans for how their needs in respect of health and welfare will be met. These plans must be kept under review and amended when any element of care and support need changes. 11/07/2009 This must be done to ensure that any need in regards to health and welfare are adequately assessed and met. 2 20 13 The registered person must 11/05/2009 make arrangements for the recording, handling, safekeeping, safe-administration and disposal of medications received into the care home, in that, any errors identified in justified stock audit checks must be fully investigated and appropriate actions taken in regards to the Page 29 of 32 Care Homes for Adults (18-65 years) health and welfare of residents. To ensure that residents are being administered their medication correctly by staff and to ensure that appropriate action is taken in regards to any errors. 3 23 17 The registered person must 11/05/2009 ensure that there is a record of all money and valuables held in safe-keeping on behalf of any resident. To protect residents from financial abuse. 4 24 23 Damaged floor covering on the first floor must be repaired or replaced. 17/04/2009 To prevent trip hazards. 5 42 23 The fire evacuation procedures, fire risk assessment and building floor plan must be updated. 03/04/2009 To ensure that residents are as safe as possible in the event of a fire. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 3 There should be better understanding of the cultural needs of some of the current residents so that steps can be taken to provide appropriate care and support. Care Homes for Adults (18-65 years) Page 30 of 32 2 6 Staff and residents would benefit from the introduction of guidance to the care review and care planning systems and standardising of planning and review documents. Staff and residents would benefit from the introduction of guidance to the risk assessment and risk management process and standardising of risk assessment and risk management documents. Personal care routines and personal care plans should be reviewed regularly and revised as necessary. Health action plans should be reviewed regularly and revised as necessary. The type of support that each person wants or requires to manage their finances and budget should be developed into individual financial support plans that can be reviewed along with all other elements of care and support planning. The home should have a pest control contract in place so that there are regular checks for any infestations of pests or vermin. The registered person should take steps to ensure that the staff group better reflects the cultural composition of the resident group. This will promote a better understanding of cultural needs of the residents. Both pages of the Commission registration certificate and the employers liability insurance certificate should be displayed in the home. 3 9 4 5 6 18 19 23 7 30 8 33 9 37 Care Homes for Adults (18-65 years) Page 31 of 32 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone : 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Adults (18-65 years) Page 32 of 32 - 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!