Inspection on 01/08/05 for Lakeside House

This inspection was carried out on 1st August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 45 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lakeside House 12/07/07

Lakeside House 25/01/07

Lakeside House 19/06/06

Lakeside House 02/02/06

Lakeside House 19/03/05

Lakeside House 08/11/04

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 09/07/2008.

CARE HOME ADULTS 18-65 Lakeside House 21 Chadwick Road Leytonstone London E11 1NE Lead Inspector Robert Cole Unannounced Inspection 1st August 2005 10:00am 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. Lakeside House G56 G06 S7278 Lakeside House V243087 010805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Lakeside House Address 21 Chadwick Road, Leytonstone, London, E11 1NE 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) 0208 923 6841 Mr Siddicq Yadallee Ms Emma Scarlett CRH - PC Care Home Only 8 Category(ies) of LD - Learning Disability (7) MD - Mental registration, with number Disorder (1) of places Lakeside House G56 G06 S7278 Lakeside House V243087 010805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 19th March 2005 Brief Description of the Service: Lakeside House is a residential care home registered with the CSCI to provide accommodation and support to eight adults with learning dissabilities. The home is situated in a residential area of Leytonstone, in the London Borough of Waltham Forest. The home is situated close by to shops, transport networks and other local amenities, and is in keeping with other homes in the area. The home is privately run. Lakeside House G56 G06 S7278 Lakeside House V243087 010805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 2/8/05 and was unannounced. The inspector had the opportunity of speaking with service users, staff and the homes proprietor was present throughout most of the inspection. There have been some areas of improvement since the previous inspection, noticeably around staffing levels. However, the high number of requirements set at this inspection, 45, reflects the overall poor standard of support provided by the home, and many issues need urgent attention. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Lakeside House G56 G06 S7278 Lakeside House V243087 010805 Stage 4.doc Version 1.40 Page 6 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lakeside House G56 G06 S7278 Lakeside House V243087 010805 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Lakeside House G56 G06 S7278 Lakeside House V243087 010805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3,4 and 5 The inspector was not satisfied that prospective service users are given sufficient information to help them make an informed choice about the home, both the Statement of Purpose and Service User Guide contain inaccurate information, and the admissions procedure is not in line with the actual practice of admissions according to the homes proprietor. EVIDENCE: The home has a Statement of Purpose and Service User Guide. The Statement contains information on the homes aims and objectives, and services and facilities provided. However, it does not accurately reflect the services provided by the home, for example it states that the home has the registration category of adult placement, but this is not the case. Further, the Statement is not dated, and there is no indication of when it was last reviewed, or when it is next due to be reviewed, all of this must be addressed. The Service User Guide also needs amending, again, it does not accurately reflect the services provided, for example the Guide states that the home will provide a chiropodist for service users who will visit the home weekly, but the acting manager informed the inspector that this was not the case. The Guide also needs to include a copy of the homes complaints procedure. At the last inspection it was required that the guide is produced in a format that is accessible to all service users. The guide is written in plain English, but the inspector was informed that not all current service users can read, and this requirement is consequently Lakeside House G56 G06 S7278 Lakeside House V243087 010805 Stage 4.doc Version 1.40 Page 9 repeated. The home has contracts in place for all service users, these include details of fees payable and the services provided by the home. The homes proprietor outlined the homes admission procedure to the inspector. It was said that this would involve service users having the opportunity of visiting the home, including for overnight stays, before making a decision as to move in or not. Further, existing service users would be consulted over the suitability of any potential new admissions to the home. The service user would initially move in to the home on a trial basis for six weeks, after which a placement review meeting would be held. The home had a written admissions procedure, however, this made no mention of existing service users been involved, or of the fact that the service user would initially move in on a trial basis, or that a review meeting would be held after the trial period had expired, and it is required that the admissions procedure accurately reflects the actual admissions practice, and is in line with good practice as regards admissions. There have been no new admissions to the home since the last inspection. Lakeside House G56 G06 S7278 Lakeside House V243087 010805 Stage 4.doc Version 1.40 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8,9 and 10 It is the view of the inspector that the home should be doing more to promote the individual needs and choices of service users. Service users must be involved in the running of the home, and review meetings need to take place as appropriate. EVIDENCE: Care plans are in place for all service users. The acting manager informed the inspector that the home was in the process of updating care plans at the time of inspection. The new design of care plans was clear and easy to understand. Plans included information on health, mobility and social needs. However, care plans are not comprehensive, for example, the acting manager informed the inspector that there are specific issues around one service users personal care linked to their religion, but this was not detailed or mentioned in any way in their care plan. The proprietor informed the inspector that all service users were expected to have an annual review meeting, attended by the placing authority, yet there was only evidence that one service user has had such a meeting within the past twelve months. The home had a letter from the placing authority dated the 3/7/05 requesting that the home contact the authority to arrange review meetings. The proprietor informed the inspector that this had not yet been done. It is required that the home holds review Lakeside House G56 G06 S7278 Lakeside House V243087 010805 Stage 4.doc Version 1.40 Page 11 meetings in line with the requests of the placing authority for all service users at least once every twelve months. All service users have risk assessments in place, and since the last inspection there is now a risk assessment around service users smoking in their bedrooms. Assessments were generally clear, and included risks associated with fire, falling and access to the community. Risk assessments are not however sufficiently up to date, for example the acting manager informed the inspector that it had been highlighted at a recent review meeting that one service user needs to be checked every 15 minutes throughout the night due to the risk of epilepsy, however, the risk assessment said that they should be checked every hour. Risk assessments must be regularly reviewed and cover all areas of potential risk to service users and others. The care plan for one service user stated that on occasions they exhibit challenging behaviour, yet there were no guidelines in place around managing this behaviour, and this must be addressed. There was evidence that service users have control over their daily lives, for example service users spoken to informed the inspector they are able to get up and go to bed when they want, and are able to choose their own clothes to wear. The acting manager informed the inspector that service users were involved in the running of the home, for instance in helping to plan and choose holidays, but this could not be evidenced. Service user meetings are held, although the last one to take place was in January 2005. The acting manager informed the inspector that service users are not involved in the recruitment and selection of staff to the home, and this is recommended. It is required that service users are given the opportunity of participating in the day to day running of the home, and that their involvement is recorded. The home has a confidentiality policy in place, this makes clear under what circumstances a confidence may be broken in the health, safety and welfare interests of service users and others. Staff spoken to be the inspector demonstrated a good understanding of the issues around confidentiality. Confidential records are stored securely, and staff and service users can access their records as appropriate. Lakeside House G56 G06 S7278 Lakeside House V243087 010805 Stage 4.doc Version 1.40 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,15,16 and 17 The inspector was not satisfied that service users have the opportunity of living fulfilling lives in line with their assessed needs. Service users are not been offered appropriate leisure, educational or employment opportunities, and the home must ensure that service users have access to a place of worship as appropriate. EVIDENCE: At present no service users are involved in any employment or formal educational opportunities. However, two service users have indicated that they want some form of employment, and it is required that the home actively supports service users to find appropriate employment in line with service users wishes. Similarly, service users have also expressed a desire to attend local colleges, the acting manager said they would try and arrange this, but nothing had been arranged at the time of inspection, and this must be addressed. The inspector was informed that service users are involved with in house programmes to develop independent skills such as laundry, but their was no evidence of this in place, or guidance on how the programme was to be implemented. Lakeside House G56 G06 S7278 Lakeside House V243087 010805 Stage 4.doc Version 1.40 Page 13 Service users have access to the community, for example service users visit local shops, cafes and the library. Service users access transport networks, including buses and trains, and the home has its own unmarked minibus. One service user regularly visits a temple with his family, and another service user attends a mosque on special occasions. Another service user informed the inspector that they would like to attend mosque weekly, the proprietor informed the inspector that this service user is offered the opportunity of going to mosque every Friday, but that they refuse to go, however, this was not recorded or evidenced, and it is required that the home supports service users to attend places of worship as appropriate. In house service users have access to a variety of social and leisure interests, including TV, video, music, computer games, art sessions and BBQ’s. Parties are held to celebrate birthdays and religious festivals. In the community one service user attends an African-Caribbean centre, while another attends a social group organised by MENCAP. However, there was very little evidence to suggest that the home itself arranges and provides sufficient and appropriate community based social and leisure activities for service users. For example, one service user informed the inspector that they would like to go swimming, staff informed the inspector that they were aware of this service users wishes, yet this activity has not been happening. There were no activity programmes in place for service users. All of this must be addressed. The acting manager informed the inspector that a holiday has been planned to Kent for service users later this year. The home has a visitors policy in place. Service users are able to receive visitors in private if they wish, and have access to use a phone in private. Service users are able to visit their families including for overnight stays. The home has a visitors book, this evidenced that their had only been one visitor to the home since 12/5/05, the proprietor said that this was not accurate, and it is required that the visitors book is appropriately maintained. Service users have unrestricted access to communal areas, and were observed to move freely around the home on the day of inspection. Staff were observed to knock and wait before entering bedrooms. Two service users informed the inspector that they would wish to have keys for their bedrooms, the proprietor informed the inspector that they would arrange for one of the service users to be given a key, but not the other due to health and safety reasons, yet their was no risk assessment in place around this. It is required that all service users are offered keys to their bedrooms subject to the completion of a satisfactory risk assessment which is placed on their file. Records are kept of menus, and these indicated that service users are offered a balanced, varied and nutritious diet. Service users are offered a choice of menu, and the home is able to cater for any specific dietary requirements, for example the home has separate storage facilities for Halal and non Halal food Lakeside House G56 G06 S7278 Lakeside House V243087 010805 Stage 4.doc Version 1.40 Page 14 products. Service users are involved in food preparation, including buying the food, and on the day of inspection were observed to help themselves to drinks and snacks. Food was stored appropriately, and the kitchen was clean and tidy. However, the fridge and freezer in the kitchen had no thermometers to record temperatures, new thermometers were purchased on the day of inspection and installed in the fridge and freezer. Lakeside House G56 G06 S7278 Lakeside House V243087 010805 Stage 4.doc Version 1.40 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19 and 20 Although the inspector believes that the home is meeting service users personal care needs, they have serious doubts about the homes ability to meet their medical needs, with particular regard to the safe administration, storage and recording of medications. EVIDENCE: All service users are registered with a local GP. Records are maintained of medical appointments, and these evidenced that service users have access to health professionals as appropriate, including CPN’s, psychiatrists and opticians. On the day of inspection one service user had a GP appointment, while another had a dental check up. The acting manager informed the inspector that visiting health professionals will often see service users in the homes sitting room, and it is required that service users see visiting health professionals in private. An additional unannounced inspection of the home took place on the 31/3/05. At this inspection a number of requirements were set around medication. The inspector checked progress made on these requirements, as well as requirements set at the inspection of the home n the 19/3/05. Since these inspections, the home now has a policy and procedure in place around medication, and this was readily available in the home for staff to consult. The lock on the medication cabinet has been repaired, and medications are now Lakeside House G56 G06 S7278 Lakeside House V243087 010805 Stage 4.doc Version 1.40 Page 16 stored securely, and records are maintained of medications returned to the pharmacist. However, the inspector was disappointed to note that there are still a number of areas of concern with regard to medication within the home. Many of the homes staff responsible for administering medication in the home have as yet not received appropriate training, the acting manager said that it is planned that the homes supplying pharmacist will provide this training, and this issue must be addressed. Medication Administration Record (MAR) charts are maintained, but these contained several unexplained gaps in them. Further, one service user is prescribed CHLORHEXIDINE injection. This is to be administered by the district nurse on a weekly basis, yet staff had signed MAR charts on consecutive days to indicate that it had been administered. The acting manager informed the inspector that this was an error, and it suggests that staff do not always read the instructions on MAR charts before they administer medications. There were inconsistencies on the instructions written on medication labels, and those written on the MAR charts, for example one medication label stated that the medication had been prescribed on a PRN basis, yet the MAR chart stated that this medication was to be given daily. Further, no guidelines were in place around the administering of PRN medications, and staff spoken to demonstrated a poor understanding of when they should administer PRN medications. Hand written entries on MAR charts have not been signed for. Further, after an audit of some medications, the inspector found several medications to be unaccounted for. For example, records indicated that the home should have had 10 SERTRALINE tablets in stock, yet there were only 7 tablets, and staff could give no explanation as to why there was a shortfall. All of this needs to be addressed as a matter of priority. Service users are supported to manage their own personal care as much as possible, in line with their care plans. Service users are able to choose their own clothes to wear, and all were appropriately dressed on the day of inspection. The CSCI is taking enforcement action regarding the homes repeated failure to comply with safe medication administration procedures. Lakeside House G56 G06 S7278 Lakeside House V243087 010805 Stage 4.doc Version 1.40 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 It is the judgement of the inspector that service users are been put at risk by the homes poor policies and lack of staff training around the issues of complaints and protection. EVIDENCE: The home has a complaints procedure, this included timescales for responding to any complaints made, but did not state that the CSCI can be contacted at any stage with a complaint, or give contact details of the CSCI. The procedure was not on display within the home, and it is recommended that it be prominently displayed within the home. The procedure is in written English, and it is required that it is produced in a format which makes it accessible to all service users. The proprietor informed the inspector that the home maintains a complaints log, however, this could not be found on the day of inspection, and it is required that the home maintains a complaints log, and that this is available for inspection by persons so authorised to do so. The home does not have a copy of the Local Authorities adult protection procedure, and must obtain one. It does have its own policy in place on adult protection. However, this dates from 1998, and is not in line with current legislation. For example, it does not fully set out the action to be taken by staff and management in the event of a suspected case of abuse. The proprietor informed the inspector that none of the current staff team has received training in issues around adult protection. All of this must be addressed. The home holds money on behalf of service users in a locked cabinet. Records and receipts are maintained of financial transactions involving service users monies. The inspector checked several sets of service users monies, and all appeared to be satisfactory. Lakeside House G56 G06 S7278 Lakeside House V243087 010805 Stage 4.doc Version 1.40 Page 18 Lakeside House G56 G06 S7278 Lakeside House V243087 010805 Stage 4.doc Version 1.40 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27,28,29 and 30 The inspector believes that the home physical environment is suitable to meet its stated purpose. Service users are provided with adequate communal and private space, and the home is generally well maintained. EVIDENCE: The home is situated in a residential area of Leytonstone in the London Borough of Waltham Forest. The home is close to shops, transport links and other local amenities, and is in keeping with other homes in the area. The home was generally well maintained both internally and externally, and on the day of inspection was clean and tidy. The communal space consists of a dining/sitting room, kitchen and garden with appropriate garden furniture. However, two doors that have been identified as fire doors, and marked with keep closed signs were found to be wedged open during the inspection, including the door leading into the kitchen, and this must be addressed. The home has two bathroom/toilets and three toilets on their own. All bathrooms had working locks fitted and were clean, tidy and free from offensive odour. However, the upstairs bathroom had no floor covering, the proprietor informed the inspector that this issue would be addressed soon, and this is required. Lakeside House G56 G06 S7278 Lakeside House V243087 010805 Stage 4.doc Version 1.40 Page 20 All service users have their own bedrooms. Bedrooms have hand basins in them, and adequate natural light and ventilation. Bedrooms have been personalised to service users individual taste, for instance with televisions and family photographs. Bedding, carpets and curtains were generally well maintained and domestic in character. Rooms had appropriate furniture, and meet National Minimum Standards on size requirements. The home has a policy in place on infection control, and COSHH products were stored securely. Protective clothing such as latex gloves are available to staff. The home has separate laundry facilities, and hand washing facilities are situated throughout the home. Lakeside House G56 G06 S7278 Lakeside House V243087 010805 Stage 4.doc Version 1.40 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35 and 36 While the inspector was satisfied that staff are employed in sufficient numbers to meet service users needs, they feel that staff and service users would both benefit enormously from appropriate staff training and supervision. EVIDENCE: The home provides 24-hour support including a waking night staff. There was a staffing rota on display, and this accurately reflected the actual staffing situation on the day of inspection. Since the last inspection the home now has a third staff member on duty during the busy period of the early shift, and staff are allocated time at the beginning of every shift to carry out a handover from one shift to the next. The inspector was informed that the home does not have an emergency on-call procedure, and that in the past staff were expected to call the homes manager in the event of an emergency. However, as the manager has now left the home, it is required that there is an emergency oncall procedure in place, and that all staff are familiar with it. The home has policies in place on equal opportunities and recruitment and selection. Staff spoken to informed the inspector that when applying for their jobs they were interviewed by just one person, the homes manager. It is required that staff recruitment follows good practice as regards to equal opportunities, including ensuring that interviews are conducted by at least two Lakeside House G56 G06 S7278 Lakeside House V243087 010805 Stage 4.doc Version 1.40 Page 22 people. The inspector checked several staff files at random. These evidenced that the home had checked passports and birth certificates, and taken up references for staff. However, files did not contain a full employment history for staff, and it is required that the home has a written record of all staff’s previous employment including an account of any gaps in employment. A member of the staff team joined the home in June of this year, yet the CRB that the home had for them was dated from June 2003, and it is required that the home carries out satisfactory CRB checks on all staff prior to them commencing work at the home. Staff informed the inspector that they have been given a copy of their job description. Staff informed the inspector that they have recently received training in dental hygiene, care planning and challenging behaviour. However, the inspector has concerns that staff have not had appropriate training around the needs of service users, for instance, two service users have mental health needs, three service users have epilepsy and all service users have a learning disability, yet staff have not received any training in these subjects. Further, staff have not received all necessary statutory health and safety training, for example some staff have not had any training in food hygiene, fire safety or first aid. All of this must be addressed. The inspector was informed that of the nine care staff employed at the home three are currently working towards a relevant NVQ qualification, and that it is planned that a further two staff will start this qualification in the near future. At present there are no arrangements in place for staff supervision. The inspector was informed that historically the level of supervision has been very low, for example one member of the staff team has had just one supervision in the past twelve months, further, staff have not received a written copy of their supervision notes. It is required that arrangements are made for all staff to receive regular formal supervision, at least six times a year, and that they receive a copy of the minutes from the supervision. Lakeside House G56 G06 S7278 Lakeside House V243087 010805 Stage 4.doc Version 1.40 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,39,40,41 and 42 The inspector was not satisfied that the home has satisfactory management arrangements in place. Record keeping and policies are of a poor standard, and staff were not clear what the management arrangements for the home were. EVIDENCE: The homes previous registered manager resigned from her post in the week prior to the inspection. When the inspector arrived at the home, staff questioned were unaware if any arrangements had been made to appoint an acting manager, or who was currently responsible for the day to day running of the home. When the proprietor arrived he informed the inspector that he would shortly be contacting an employment agency to provide an acting manager, and would begin the process of recruiting a permanent manager with a view to them been registered with the CSCI. During the course of the inspection the proprietor informed the inspector that in the interim period, the homes senior carer will be acting as the homes manager. It is required that the Lakeside House G56 G06 S7278 Lakeside House V243087 010805 Stage 4.doc Version 1.40 Page 24 home appoints a suitably qualified and experienced permanent manager who is registered with the CSCI. The home holds regular staff meetings, and care plans are reviewed monthly, both of which contribute to quality assurance within the home. Copies of previous inspection reports were available in the home. The CSCI has not been sent a copy of a Regulation 26 visit report since May 2004, and there was no evidence in the home to indicate that any subsequent visits have taken place, and it is required that the proprietor carries out monthly unannounced Regulation 26 visits, and that a copy of the report of these visits is forwarded to the CSCI and a copy retained in the home. No attempts are made to seek the views of service users, their relatives or staff on the quality of care provided by the home, and it is required that systems are put in place to gain their views, to help inform future planning. The inspector checked several policies and procedures at random, and found that many of them were not in line with current legislation or National Minimum Standards, such as policies on complaints and adult protection. This must be addressed. The inspector also had concerns around the poor standing of record keeping in the home, for instance risk assessment have not been kept up to date, and several gaps existed on MAR charts. Records are however held securely as appropriate. Fire fighting equipment was situated throughout the home, and was last serviced in June 2005. Fire exits were free from obstruction on the day of inspection. There was evidence that the home holds regular fire drills, and fire alarms are tested weekly, and were last serviced by an engineer on the 20/8/04. The home had evidence that PAT, gas and the electrical installations had all been safety checked within appropriate timescales. COSHH products were stored securely. However, the home does not test hot water temperatures used for personal care. It is required that the home checks and records all hot water outlets used for personal care at least once a week to ensure temperatures are at 43 degrees centigrade. Lakeside House G56 G06 S7278 Lakeside House V243087 010805 Stage 4.doc Version 1.40 Page 25 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 2 2 3 Standard No 22 23 ENVIRONMENT Score 1 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 1 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 2 2 x 3 Standard No 11 12 13 14 15 16 17 2 1 3 2 2 2 3 Standard No 31 32 33 34 35 36 Score 3 3 2 2 1 1 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Lakeside House Score 3 2 1 x Standard No 37 38 39 40 41 42 43 Score 1 x 1 2 2 2 x G56 G06 S7278 Lakeside House V243087 010805 Stage 4.doc Version 1.40 Page 26 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 5 Requirement The registered person must ensure that the Service User Guide is presented in an accessible format to meet the communication needs of the service users and ensure it is in line with Regulation 5 of the Care Homes Regulations 2001. (Timescale 1/5/05 not met) The registered person must ensure service users have access to and choose from a appropriate leisure activities. (Timescale 1/5/05 not met) The registered person must ensure the homes Statement of Purpose is developed in line with Schedule 1 of the Care Homes Regulations 2001. (Timescale 1/5/05 not met) The registered person must ensure service users have the opportunity to participate and contribute to the running of the home, documentary evidence of this must be provided. (Timescale 1/5/05 not met) The registered person must in discussion with service users enable them to take part in learning opportunities G56 G06 S7278 Lakeside House V243087 010805 Stage 4.doc Timescale for action 30/11/05 2. YA14 16 30/11/05 3. YA1 4 30/11/05 4. YA8 12 30/11/05 5. YA12 16 30/11/05 Lakeside House Version 1.40 Page 27 6. YA14 16 7. YA20 13 appropriate to their need. (Timescale 1/5/05 not met) The registered person must ensure that service users are supported to take part in appropriate leisure activities both inside and outside the home. (Timescale 1/5/05 not met) The registered person must ensure staff adhere to the homes procedure on administering medication. (Timescale 1/5/05 not met) The registered person must review the format of the complaints procedure to ensure that it is accessible to service users. (Timescale 1/5/05 not met) The registered person must make arrangements to have the floor covering in the bathroom replaced. (Timescale 1/5/05 not met) The registered person must ensure that the homes admissions procedure accuratley reflects the actual practice of admitting service users to the home. The resgistered person must ensure that service users care plans clearly set out how the home can meet all the assessed needs of service users. The registered person must ensure that the home holds regular review meetings for all service users, at least once a year, in line with the request of the placing authority. The registered person must ensure that regular service user meetings are held. The registered person must ensure that comprehensive risk G56 G06 S7278 Lakeside House V243087 010805 Stage 4.doc 30/11/05 8. YA22 22 See section on Personal and Healthcare in report. 30/11/05 9. YA27 23 30/11/05 10. YA4 14 30/11/05 11. YA6 15 30/11/05 12. YA6 15 30/11/05 13. 14. YA8 YA9 12 13 30/11/05 30/11/05 Page 28 Lakeside House Version 1.40 15. YA9 13 16. YA11 12 17. YA12 16 18. 19. YA15 YA16 17 12 20. YA19 12 21. YA20 13 22. YA20 13 assessments are in place for all service users, covering all areas of potential risk to themselves and others, and that these assessments are regularly reviewed. The registered person must ensure that the home has clear guidelines in place on the managing of any challenging behaviours exhibited by individual service users. The registered person must ensure that arrangements are in place to enable service users to visit a place of worship of their choice. The registered person must ensure that the home supports service users to participate in appropriate educational and employment opportunities in line with their assessed needs and stated preference. The registered person must ensure that the home keeps a record of all visitors to the home. The registered person must ensure that all service users are offered keys to their bedrooms, subject to satisfactory risk assessments. The registered person must ensure that service users are able to see visiting health proffessionals in private. The registered person must ensure that all staff undertake appropriate training in the handling, recording, storage, administration and disposal of medications. The registered person must ensure that all medications administetred are appropriatley accounted for. 30/11/05 30/11/05 30/11/05 30/11/05 30/11/05 30/11/05 See section on Personal and Healthcare in report. See section on Personal and Healthcare in report. Page 29 Lakeside House G56 G06 S7278 Lakeside House V243087 010805 Stage 4.doc Version 1.40 23. YA20 13 The registered person must ensure that MAR charts are appropriatly and accuratley maintained. 24. YA20 13 25. YA20 13 26. YA20 13 27. YA22 22 28. YA22 22 29. YA23 13 30. YA23 13 See section on Personal and Healthcare in report. The registered person must See section on ensure that the prescribing instructions for medications Personal written on MAR charts are and consistant with those instructions Healthcare written on the medications label, in report. and that both of these are in line with the prescribing instructions of the medical practitioner who prescribed the medication. The registered person must See section ensure that all hand written on entries on MAR charts are signed Personal for. and Healthcare in report. The registered person must See section ensure that the home has clear on guidelines in place on the Personal administration of all individual and medications prescribed on a PRN Healthcare basis. in report. The registered person must 30/11/05 ensure that the homes complaints procedure includes appropriate reference to the CSCI. The registered person must 30/11/05 ensure that the home maintains a complaints log, which includes details of any complaints received, investigations, outcomes and action taken. The registered person must 30/11/05 ensure that the home has a copy of the Local Authorities procedures for dealing with adult protection issues. The registered person must 30/11/05 ensure that the homes policy and procedure on adult protection are in line with G56 G06 S7278 Lakeside House V243087 010805 Stage 4.doc Version 1.40 Page 30 Lakeside House current legislation. 31. YA23 13 The registered person must ensure that all staff emplyed at the home receive appropriate training around adult protection issues. The registered person must ensure that identified fire doors within the home are not left wedged open. The registered person must ensure that the home has an emergency on-call procedure, which is understood and readily accessible to all staff. The registered person must ensure that all staff recruitment is carried out in line with good practice as regards to equal opportunities. The registered person must ensure that the home carries out a satisfactory CRB check on all new staff prior to them commencing work in the home. The registered person must ensure that the home has a full written records of staffs employment history, including any gaps in employment. The registered person must ensure that staff receive appropriate training in the following areas: 1. working with adults with learning disabilities, 2. working with adults with mental health needs, and 3. epilepsy. The registered person must ensure that all staff receive all statutory health and safety training as appropriate. The registered person must ensure that all staff receive regular formal supervision at least six times a year, and that they get a copy of the minutes of 30/11/05 32. YA28 13 and 23 30/11/05 33. YA33 13 30/11/05 34. YA34 19 30/11/05 35. YA34 19 30/11/05 36. YA34 19 30/11/05 37. YA35 18 30/11/05 38. YA35 18 30/11/05 39. YA36 18 30/11/05 Lakeside House G56 G06 S7278 Lakeside House V243087 010805 Stage 4.doc Version 1.40 Page 31 the supervision. 40. YA37 8 and 9 The registered person must appoint a suitably qualified and experienced manager to the home, and apply for their registration with the CSCI. The registered person must ensure that monthly unannounced Regulation 26 visits are carried out at the home, and that a copy of the report of the visit is forwarded to the CSCI, and a copy retained in the home. The registered person must ensure that the home has all policies and procedures required in line with National Minimum Standards and the Care Home Regulations 2001, and that these policies are up to date and accurate. The registered person must ensure that the home maintains all records required by the National Minimum Standards and the Care Home Regulations 2001. The registered person must ensure that all hot water outlets used for personal care are checked and recorded at least once a week to ensure that the temperature is 43 degrees centigrade. The registered person must ensure that the homes Statement of Purpose is dated and regularly reviewed. 30/11/05 41. YA39 26 30/11/05 42. YA40 17 30/11/05 43. YA41 17 30/11/05 44. YA42 13 30/11/05 45. YA1 4 and 6 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations G56 G06 S7278 Lakeside House V243087 010805 Stage 4.doc Version 1.40 Page 32 Lakeside House 1. 2. Standard YA8 YA22 It is recommended that service users at the home are given the opportunity of been involved in the recruitment and selcetion of all staff to the home. It is recommended that the homes complaints procedure is prominently displayed within the home. Lakeside House G56 G06 S7278 Lakeside House V243087 010805 Stage 4.doc Version 1.40 Page 33 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 Lakeside House G56 G06 S7278 Lakeside House V243087 010805 Stage 4.doc Version 1.40 Page 34 - 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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