Inspection on 23/04/05 for Kirkstall Lodge

This inspection was carried out on 23rd April 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 but made no statutory requirements on the home.

Other inspections for this house

Kirkstall Lodge 25/05/07

Kirkstall Lodge 21/11/06

Kirkstall Lodge 25/07/06

Kirkstall Lodge 06/10/05

Kirkstall Lodge 07/02/05

Kirkstall Lodge 08/09/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

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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 09/07/2008.

CARE HOME ADULTS 18-65 Kirkstall Lodge Kirkstall Lodge 56 Kirkstall Road Streatham London SW2 4HF Lead Inspector Mary Magee Unannounced 23,25/04/05 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. Name G52-G02 S53104 Kirkstall Lodge V223675 230405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Kirkstall Lodge Address 56 Kirkstall Road, Streatham, London, SW2 4HF 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) 01491 579 270 Kirkstall Lodge Limited Ms Thessel Carter CRH Care Home 6 Category(ies) of PC Care Home only registration, with number of places Name G52-G02 S53104 Kirkstall Lodge V223675 230405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th February 205 Brief Description of the Service: Kirkstall Lodge is a care home for six adults with a learning disability. The premises a semi detached house is located in a residential street in Streatham, South West london. It is close to public transport routes, shops and leisure facilities. It is two storey and is unsuitable for people with very restricted mobility as the front access is via a number of steps. The garden is not very big as some of the space is used to a garden house that is used an office. As the house are very closely linked noise can be transmitted very easily, therefore there must be a consideration to this when offering new service users a place at the home. The home is owned and managed by Beacon Care, a private care provider with many other homes in London and the South East of England. Currently the home provides 24-hour care and support to five adults, all of them had lived together in a previous home in Battersea that has now closed. Support is provided by a staff team of support workers and a home manager.The service users accommodated are supported to attend day services and community activities. The home has use of a vehicle and employs a support worker/driver to assist with the numerous journeys back and forth to the various day services/activities attended Name G52-G02 S53104 Kirkstall Lodge V223675 230405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken over two days. It was carried out in response to concerns raised by neighbours on the suitability of the placement of one service user that lived at the home. On the first day the inspection commenced at 6am. Two hours were spent while night staff completed their shift. The inspectors looked around most parts of the building. Four service users, two members of staff spoken to. A number of records were viewed on both days. The second day of the inspection was spent with the manager discussing the progress made in addressing the requirements set at the previous inspections. What the service does well: What has improved since the last inspection? What they could do better: The management has not been effective in addressing the many areas of concern raised at the previous inspection and requires more support and guidance. Areas of concern are set out below. The home has accommodated service users without giving sufficient consideration to appropriateness of the home; this has resulted in a service user not receiving a service that meets his assessed needs. This must be addressed urgently. Assessment and care planning must improve so that staff know how to care for each individual and understand their method of communication. Name G52-G02 S53104 Kirkstall Lodge V223675 230405 Stage 4.doc Version 1.30 Page 6 Communication generally requires much improvement particularly with written records. Staff must be employed correctly and receive the necessary support and supervision so that people living at the home are protected and safe and benefit from a skilled staff team that have the right qualities and attributes. Complaints must be responded to promptly and correctly so that people making complaints know that they are being listened to. A meeting was held with the CSCI and the regional care manager for Beacon Care London Region to discuss the areas of concern highlighted following the inspection. It was agreed that an action plan was put in place to address all the issues as a matter of urgency. 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. Name G52-G02 S53104 Kirkstall Lodge V223675 230405 Stage 4.doc Version 1.30 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 Name G52-G02 S53104 Kirkstall Lodge V223675 230405 Stage 4.doc Version 1.30 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 3 Not all the staff team have the qualities and characteristics required for their role. The attitude adopted by some of the night staff was poor and showed little signs of empathy with the service users. EVIDENCE: The manager informed the inspector that the Statement of purpose and the Service user’s Guide had been updated. Copies of these had not been circulated to service users or families. These must be circulated and made available for prospective service users/families. All the service users had lived together in a home in Battersea that had closed in 2004. No new service users have been admitted since the last inspection. There were indications that the home is not meeting the needs of current service users. Recently a service user with learning disabilities and challenging needs had absconded during the night and was found some miles away by police. It raises concerns about the supervision and support provided during the night by staff. He demonstrates increasing signs of boredom and lack of suitable stimulation, examples such as playing with the soil in the garden. The home and the garden are not spacious, the service user is unable to use his excess energy or have any focus. His grandmother/guardian spoke to the inspector about the lack of stimulation available to him at the home and questioned the suitability of the placement. His needs had not been considered fully when he moved into kirstall lodge. A multidisciplinary meeting Name G52-G02 S53104 Kirkstall Lodge V223675 230405 Stage 4.doc Version 1.30 Page 9 was held to discuss the best way forward in meeting the young man’s needs. He had been unable to access any services in the community recently as the risk of absconding was too great, It had been agreed that additional one to one staffing was required during the day to support him when going into the community. At the time of inspection this increased staffing level had not been supplied and little progress had been made in meeting his needs. Other indications were observed demonstrating the home was not fully meeting the needs of service users. One service user that woke early and greeted the inspectors when he entered the lounge, he was non-verbal and indicated that he would like a hot drink. The night staff member did not respond to this and ignored his request. This demonstrated how little she understood the needs of service users despite the fact that she had worked there for over seven months and had worked with the service user at his previous placement. Name G52-G02 S53104 Kirkstall Lodge V223675 230405 Stage 4.doc Version 1.30 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 Limited progress has been made in the arrangements made for meeting the social and healthcare needs of individuals. Care plans and risk assessments have not been kept up to date, neither have staff become familiar with the changes. All staff members do not understand the method of communication used by service users. EVIDENCE: Care plans were in place for all service users. Two of these were examined. It was found that these had not been updated, neither had risk assessments been reviewed or updated to reflect major changes. From discussions with three members of staff it was evident that not all staff were familiar with the needs of individuals. Where service users are non verbal plans must contain details of individual mode of communication, staff must also be aware of how to communicate with service users at the home. On both days of the inspection it was observed that service users were offered little opportunity to participate in the day to day running of the home, staff were not familiar with signed communication, the use of objects of reference, or the individual communications needs of the service users accommodated. A service user displaying challenging needs had very little information regarding personal goals recorded in his care plan. Limitations had been placed on him accessing Name G52-G02 S53104 Kirkstall Lodge V223675 230405 Stage 4.doc Version 1.30 Page 11 the community due to the risk assessed, it had been agreed that staffing ratios of one to one for the day would be provided to avoid this limitation. However this action had not occurred. Risk assessments need to be improved, plans must include procedures to be adopted for people likely to be aggressive. Some disparity was found in the way members of staff recorded incidents, an example where the support worker described the incident to the inspector was very different to the written record of the event. On day two the inspector met with the manager. Accounts and cash boxes were held for all service users. The account balances were not clear and did not demonstrate that statements were kept up to date. Name G52-G02 S53104 Kirkstall Lodge V223675 230405 Stage 4.doc Version 1.30 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 15 16 17 The home has not considered the assessed needs of all those accommodated which has resulted in one service user not achieving the best outcome. It is unable to provide all the appropriate support required to enable individual service users to lead fulfilling lifestyles. The storage of food is poor and places service users at unnecessary risk. EVIDENCE: While the majority of service users are given opportunities for personal development and are supported to attend day centres, college there are concerns that one young energetic man is not receiving appropriate opportunities. His grandmother/guardian expressed her concern to the inspector. He has displayed some challenging needs that have not been managed appropriately, Staffing requirements that address his needs and enable him to lead a fulfilling lifestyle are needed. Records indicated that where possible service users were enabled to maintain contact with family and friends. Also individuals receive encouragement and support to develop appropriate personal relationships. Menus indicated that a variety of meals were planned for and served at the home. Food storage was poor, meat was stored in plastic bags and held in the freezer, there were no labels or dates to Name G52-G02 S53104 Kirkstall Lodge V223675 230405 Stage 4.doc Version 1.30 Page 13 indicate the contents or when they had been purchased. One service user with challenging behaviour had a regular high intake of biscuits; there were no indications that he was offered fresh fruit or any healthier alternatives or that his pattern of behaviour had been monitored. No consultation had taken place with the dietician. The inspector was disappointed to find that on rising service users were not offered hot drinks, one member of staff did not take the time to observed that a service user was signing to indicate that he would like a cup of tea. The interaction observed between night staff and service users was not appropriate. Night staff did not talk to service users or wish them good morning when they entered the lounge. Locks were provided on bathroom and toilet doors, these had been repaired following a requirements set at the previous inspection. Name G52-G02 S53104 Kirkstall Lodge V223675 230405 Stage 4.doc Version 1.30 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) 20 Progress has been achieved in the medication procedures at the home but further improvements are required in the auditing of medication held at the home. In order to ensure that service users are not placed at risk it is imperative that an assessment of the competencies of all staff in administering medication is undertaken. EVIDENCE: Medication is store securely at the home. Medication records observed were clear, no omissions were observed in charts for medication administered. The home had ceased the poor practice of applying medication labels printed by the pharmacist on the MAR sheets. Medication training had been obtained for all staff as required in the previous inspection report, although individual staff assessment was still to be arranged. No audits are undertaken of medication stock checks in the home. This was detailed as requirement at the previous inspection. Name G52-G02 S53104 Kirkstall Lodge V223675 230405 Stage 4.doc Version 1.30 Page 15 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 The home has not developed an effective complaints procedure and complaints are not handled objectively. Improvements are need in the way individuals’ finances are accounted for. EVIDENCE: The inspectors undertook this inspection in response to a concern raised by a neighbour. He had been concerned that a service user might be at risk. Frequently for the past few months during the early mornings neighbours were woken by the loud noise from a service user. On the day of inspection it was found that the young service user had ritualistic behaviour, he liked to go into the bath and shout loudly out of the bathroom window. Staff had been advised to shut the windows when this occurred. This had not been done. The complaints book contained ten complaints lodged by neighbours since November 04, all instances where the management of a service user had impacted on neighbours. The home had done little to respond to the neighbours concerns except record the instances, there were no action plans to address complaints. The formatting of complaints with the action taken and the outcomes was detailed as a requirement in the previous inspection report. The home had made little effort to develop effective relationships with the local community. No complaints had been received from service users. One relative spoke to the inspector; she had found the team leader to have a poor attitude when she raised concerns with him about her grandson. Staff demonstrated knowledge of adult protection procedures when spoken to by inspectors. There were concerns that the CSCI had not been notified of incidents affecting service users. This area has improved, a week prior to the inspection an incident occurred where notification had not been made within acceptable period, it concerned a service user that had made his way to the local park Name G52-G02 S53104 Kirkstall Lodge V223675 230405 Stage 4.doc Version 1.30 Page 16 when he was escorted by staff. The written record examined by the inspectors indicated that restraint was used. The member of staff involved confirmed that restraint was not used but he was unaware of the inaccuracy of the written record he had completed. The procedures adopted by the home to manage service users’ financial affairs were viewed. The records were not well ordered; the balances were not completed for each transaction undertaken and therefore did not give an accurate picture of the state of individual finances. Cash held did tally with overall balances. Name G52-G02 S53104 Kirkstall Lodge V223675 230405 Stage 4.doc Version 1.30 Page 17 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 26 27 28 29 30 The premises are bright and attractive and offer a homely environment. The garden is small and quite restrictive and is unsuitable for young energetic people who like and require lots of space. EVIDENCE: During a tour of the premises the inspectors found the premises were bright, clean and comfortable and were large enough to accommodate six service users. The home was well ventilated and free from unpleasant odours. The home was in keeping with other homes in the area, and was indistinguishable as a care home. Bathroom and toilet facilities were in good order. Suitable and appropriate communal facilities are provided. An OT has assessed these. Work had commenced on the provision of suitable adaptations and was within acceptable timescales, this also included the levelling of the garden path. Name G52-G02 S53104 Kirkstall Lodge V223675 230405 Stage 4.doc Version 1.30 Page 18 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) 32 33 34 36 Recruitment procedures are not robust and do not provide the safeguards to offer protection to people living at the home. The deployment of a number of staff that have worked at another home and that lack the essential qualities and skills is not adequate and impacts on the ability of the home to meet the needs of service users. EVIDENCE: The inspectors found that night staff lacked the essential qualities and attributes to care for individuals with learning disabilities. They were not interested and were unable to communicate and understand the needs of people with non-verbal communication. Records viewed indicated that one member of staff found that her work at the home had affected her studies. There were indications that she had prioritised her studies rather than her role in supporting people. Day staff were more interested and understood the needs of service users. The inspectors found that not al of the team of support workers had the necessary specialist skills to meet service users individual needs, including skills in communication and dealing with anticipated behaviours. On the recruitment files there were areas of omissions noted, two members of staff had been written to regarding their emigration status. They had failed to respond positively to the letters. Another member of staff employed did not have a POVA check completed before he commenced Name G52-G02 S53104 Kirkstall Lodge V223675 230405 Stage 4.doc Version 1.30 Page 19 employment. Records of supervision and conversations with staff members indicated that they were not regularly and consistently supervised. Name G52-G02 S53104 Kirkstall Lodge V223675 230405 Stage 4.doc Version 1.30 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 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 40 41 The management of the home has not been effective with no support or supervision available consistently. This has resulted in service users not receiving a consistent quality of care and in the poor practices demonstrated by some staff not been identified and addressed. EVIDENCE: The registered manager has a diploma in social work and experience in working within the learning disability field. She caring and dedicated but has not experienced managing a team of support workers. She has been in post for eight months and completed her registration with the Commission. She has inherited a staff team that comprises of a number of staff that had worked together at a home that has now closed, there have been difficulties experienced managing the staff team. It had been agreed at the time of registration that she required additional support with her role. She has received training in delivering supervision but has not benefited from the necessary support required to effectively manage the staff team. Staff have not received the necessary supervision and support required, areas of poor Name G52-G02 S53104 Kirkstall Lodge V223675 230405 Stage 4.doc Version 1.30 Page 21 practice have not been addressed. An annual development programme has not formulated for the home. Policies and procedures had been reviewed however they had not been signed and dated. Staff spoken to were aware of the fire evacuation procedures and of the regular fire drills conducted. The side gate had been locked to prevent one service user from absconding from the garden. The inspector advised the manager to seek the advice of the fire prevention officer on correct procedures to follow when the side exit was locked. Advice was taken from LEFDA on changes to evacuation procedures; the advice given on the visit was that the front door is the main exit route in the event of a fire. Two service users at the home experienced an outbreak of food poisoning recently; environmental health inspectors had visited the home. It was unclear where the outbreak originated and it was not confirmed that the home as the source. Necessary precautions had been taken to prevent the spread of this outbreak at the time. Temperatures are recorded regularly at the home of hot food, fridges and freezers. Although the home had experienced the food poisoning outbreak careful consideration had not been given to safe storage of perishable food. There were no labels to indicate the contents or dates on food bags containing meat that were stored in the fridge and freezer. Name G52-G02 S53104 Kirkstall Lodge V223675 230405 Stage 4.doc Version 1.30 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 2 x 1 x x Standard No 22 23 ENVIRONMENT Score 1 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 1 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 3 2 2 3 Standard No 11 12 13 14 15 16 17 2 x x x 3 2 2 Standard No 31 32 33 34 35 36 Score x 1 1 2 2 1 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Name Score x x 2 x Standard No 37 38 39 40 41 42 43 Score 2 x 2 2 x 2 x G52-G02 S53104 Kirkstall Lodge V223675 230405 Stage 4.doc Version 1.30 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 1 Regulation 4 Sche 1 Requirement Copies of the updated Statement of purpose and the Service Users guide must be made available to service users/families and to prospective service users The home must ensure that it has the capacity to meet the needs of individuals admitted, and that staff individually and collectively have the skills and experience to deliver the services that the home offers to provide The home must not offer a place to someone whose needs they know they cannot meet. Agreements made at Multidisciplinary meetings regarding increasing staffing levels must be adhered to Care plans must be kept under review, and updated regularly to reflect current and changing needs, agreed care plans to be signed and dated ny the manager and the service user. Within agreed timescales.. More clarity by staff is required when recording incidents indicating limitations on facilities Timescale for action 30/06/05 2. 3 14 (1) a,d 18 (1) a 30/06/05 3. 4. 3 3 14 910 18 (1) a 30/06/05 30/06/05 5. 6 12 15 20/05/05 6. 7 12 17 30/06/05 Name G52-G02 S53104 Kirkstall Lodge V223675 230405 Stage 4.doc Version 1.30 Page 24 7. 8 23 16 12 8. 9 13 9. 11 10. 16 33 12 (5) a 18 11. 17 12 (1) b 12. 13. 17 42 20 13 (4) c 13 17 and choice to prevent self harm is required to recording Service users must be offered opportunities to participate in the day to day running of the home (staff training in signed communication, the use of objects of reference, and the individual communications needs of the service users accommodated will increase the ability of the service to meet this requirement) Subject of a previous requirement that remains within permitted timescalesunmet. The registered person must ensure that risk assessment documentation is dated and reviewed on a periodic basis or when circumstances change. Not met for 31/03/05 The home must provide adequate provision for service users to have opportunities for personal development. The home must ensure that individual rights are respected and that staff have the skills and the knowledge to communicate effectively with service users Service users nutritional needs to be assessed and reviewed, including the riisks associated with eating excessive amounts of sugary snacks Food stored in the fridge or the freezer must be dated and labelled The registered person must ensure that a record of the results of regular medication stock checks are recorded and maintained in the home. Within specified timescales. Not much progress had been towards addressing this. 24/06/05 30/06/05 30/06/05 30/06/05 30/06/05 30/06/05 29/04/05 Name G52-G02 S53104 Kirkstall Lodge V223675 230405 Stage 4.doc Version 1.30 Page 25 14. 20 13 18 15. 22 17 (2) 16. 22 26 17. 23 41 20 17 18. 23 37 19. 28 12 16 23 20. Name 29 13 14 23 The registered person must ensure that medication training for staf includes individual competence assessments. Within timescales, little progress had been made towards addressing this. The registered person must ensure that the log of complaints made in the home is formatted to allow actions taken, timescales and outcomes of the complaint to be recorded (whether the complaint was substantiated, partly substantiated or not substantiated). Timescale of 29/04/05 not met The record of complaints made in the home must be signed by the registered home manager and the responsible individual, or his representative, on a regular basis (monthly Timescale of 29/04/05 not met). The registered person must ensure financial procedures in place at the home in regard to service users finances are followed (individual financial records must be completed in full) Timescale of 23/05/05 not met The registered person must ensure that procedures in place in the home for notifying the CSCI of significant events includes procedures to be followed in the event that the home manager is not on duty The registered person must ensure that the rear garden path is suitable to meet the needs of all service users (the uneven surface must be repaired or replaced). The registered person must provide evidence that aids and 29/04/05 30/07/05 30/07/05 30/07/05 29/05/05 27/05/05 20/05/05 Page 26 G52-G02 S53104 Kirkstall Lodge V223675 230405 Stage 4.doc Version 1.30 21. 22. 32 34 18 19 13 23. 35 18 24. 25. 36 37 18 9 10 10 18 (1) c 24 26. 39 27. 40 12 18 23 adaptations in the home have been provided subsequent to assessment and recommendation by a suitably qualified specialist. A minimum of 50 care staff must have achieved NVQ Level 2 by 2005 Essential information must be available on all staff files, CRB and POVA checks must be sought for all new staff before they commence work at the home The registered person must ensure that a staff training and development programme, which meets sector skills council workforce training targets and ensures that staff are able to fulfil the aims of the home and meet the needs of the service users, is developed Staff must receive regular and consistent supervision that focuses on good practice. The registered manager must receive the support and guidance necessary to effectively manage the staff team The registered person must ensure that an annual development plan is formulated, based on a systematic cycle of planning-action-review, reflecting aims and outcomes for service users. The registered person must ensure that policies and procedures are available covering all topics deemed appropriate to the setting (from the list in Appendix 2 of the National Minimum Standards for Younger Adults). These policies, procedures and codes of practice must be signed, dated, reviewed and amended by the registered 31/12/05 30/06/05 27/05/05 30/05/05 30/06/05 27/05/05 30/06/05 Name G52-G02 S53104 Kirkstall Lodge V223675 230405 Stage 4.doc Version 1.30 Page 27 manager. Not met by 31/03/05 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. Refer to Standard Good Practice Recommendations Name G52-G02 S53104 Kirkstall Lodge V223675 230405 Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection Address 1 Address 2 Address 3 Address 4 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 Name G52-G02 S53104 Kirkstall Lodge V223675 230405 Stage 4.doc Version 1.30 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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