Inspection on 12/07/07 for Lakeside House

This inspection was carried out on 12th July 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lakeside House 25/01/07

Lakeside House 19/06/06

Lakeside House 02/02/06

Lakeside House 01/08/05

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 Rob Cole Unannounced Inspection 12th July 2007 10:00 DS0000007278.V345217.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000007278.V345217.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000007278.V345217.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lakeside House Address 21 Chadwick Road Leytonstone London E11 1NE 020 8923 6841 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Siddicq Yadallee Adeola Oshuwa Imode Care Home 8 Category(ies) of Learning disability (7), Mental disorder, registration, with number excluding learning disability or dementia (1) of places DS0000007278.V345217.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That a service user who has both learning disability and mental disorder may continue to reside at the home. The CSCI must be informed when this service user no longer resides at the home. 25th January 2007 Date of last inspection 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 disabilities. 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. The current rate of fees is between £600 and £900 per person per week. DS0000007278.V345217.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 12/07/07 and was unannounced. The inspector had the opportunity of speaking with service users, staff from the home, and the homes manager was present throughout the inspection. The inspection also included an examination of records and other documents, and a tour of the premises. The inspector was able to spend time during the course of the inspection observing the interaction between staff and service users, and the care and support provided, which also helped to produce evidence to support judgements made within this report. The home completed an Annual Quality Assurance Assessment prior to this visit, which was included as part of the overall inspection Process. What the service does well: What has improved since the last inspection? What they could do better: Some areas of improvement still remain, and a total of five requirements have been made. To help ensure that staff continue to develop, and to meet the needs of service users, it is required that they obtain appropriate care DS0000007278.V345217.R01.S.doc Version 5.2 Page 6 qualifications, and that they have an annual review of their performance and development needs. Medications that are administered must be appropriately recorded, to ensure that they have been administered correctly. 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. The summary of this inspection report can be made available in other formats on request. DS0000007278.V345217.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000007278.V345217.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that service users are provided with sufficient information about the home to make an informed choice as to move in or not. This information is provided through written documentation, and the opportunity of visiting the home. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place. Both documents are written in plain English. The Statement says “We aim to foster an atmosphere of care and support which enables and encourages our residents to live to their preferred lifestyle with rules and regulations kept to a minimum.” The Statement also includes details of the staff team and their qualifications, arrangements made in the home for activities, and the aims and objectives of the home. The Service User Guide has been reviewed since the previous inspection, and now includes details of the fees payable, what they cover, and what is extra. The Guide also contains information on the facilities and services provided, and details of the homes physical environment, and was in line with National Minimum Standards. DS0000007278.V345217.R01.S.doc Version 5.2 Page 9 There have been no new admissions to the home since the previous inspection. The home does however have an admissions procedure, which was appropriate. This made clear that pre-admission assessments will be carried out on any prospective service users, and that they would have the opportunity of visiting the home before making a decision as to move in or not. The procedure also stated that service users would initially move into the home on a trial basis. Written contracts/statement of terms and conditions are in place for all service users, these have been signed by the service user and a representative of the home. They include details of fees payable, and the rights and responsibilities of both parties. Through observation and discussion with service users and staff, there was evidence that the home is able to meet the needs of service users, both collectively and individually. For example, one service users first language is Urdu, and the home has recently employed a member of staff who also speaks Urdu to aid communication with this service user, and to help meet their needs with regard to equalities and diversities issues. Other examples where the home have demonstrated an ability to meet needs include the training provided, for example at previous inspections requirements were made that staff undertake training around working with adults with mental health needs, as two service users have mental health issues, and this has been addressed, and staff were able to demonstrate a good understanding of the needs of individual service users with regard to mental health issues. DS0000007278.V345217.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 and 10. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the judgement of the inspector that service users have a large measure of control over their daily lives, and that they are involved in the day to day running of the home. EVIDENCE: Individual care plans are in place for all service users. These are drawn up with the involvement of the service user, their relatives, keyworker and the senior staff within the home. Care plans are of a good standard – clear and detailed, and subject to regular review. They provide detailed information around service users health and personal care needs, and make clear that service users are supported to manage their own personal care as much as possible. Plans also include relevant information around service users social and leisure needs, and their needs around equalities and diversity issues, including DS0000007278.V345217.R01.S.doc Version 5.2 Page 11 religion, disability, sexuality and ethnicticity. Reviews have been signed by the service users to indicate their inclusion in the process. Risk assessments are in place for all service users, and as with care plans these are also of a good standard and subject to regular review. Assessments include risks associated with epilepsy, smoking and violence and aggression. Clear individual guidelines are in place on the management of any challenging behaviours that service users may exhibit. Risk assessments identify risks, and include strategies to manage and reduce these risks. The assessments make clear that service users are supported to take reasonable risks, to enable them to be able to make choices over their daily lives. For example, it has been highlighted that one service user is not aware of the potential dangers of working in a kitchen, such as electrical appliances and sharp o0bjects. However, the risk assessment sets out how this person can still work in the kitchen with appropriate staff support. There was evidence that service users have a large degree of control over their daily lives. During the course of the inspection, it was evident that service users are able to get up at a time of their choosing, choose what they wear, and have flexibility over meal times and the choice of meal. Service users are offered keys to their bedrooms, subject to the completion of satisfactory risk assessments. The homes manager informed the inspector that service users are routinely consulted over the running of the home, for instance planning activities for the day, or the days menu. The home holds regular service user meetings. One service user commented that these were “Important”, while another informed the inspector that “They are a chance to talk about things.” Meetings are minuted, and evidenced discussions on menus, activities and holidays. At a recent meeting it was noted that service users had requested new curtains for the sitting room. On examination the curtains were found to be coming towards the end of their useful life, and had several paint stains on them from a recent redecoration of the sitting room. The homes manager also expressed the view that they felt new curtains were now needed in the sitting room. It is required that the home meets the stated wishes of service users by offering them the opportunity of choosing new curtains for the sitting room. Two service users have recently had new floor coverings fitted in their bedrooms, and both service users confirmed to the inspector that they were involved in choosing these. Service users are involved in the daily routines around the home, for instance helping with cooking, laundry and keeping bedrooms tidy. This is in line with their care plans. The home has a confidentiality policy in place. However, this gave only limited information on when a confidence may have to be broken in the health, safety and welfare of service users. It stated that a service users confidence may only DS0000007278.V345217.R01.S.doc Version 5.2 Page 12 be broken when an illegal act has been committed, when in fact it should be broken when the health, safety and welfare of service users and others is seriously compromised, for example a service user may inform a staff member in confidence that they planned to self harm or commit suicide, and the staff member would have a duty to break this confidence. Staff spoken to however demonstrated a good understanding of the issues around confidentiality. DS0000007278.V345217.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that service users are supported to live valued and fulfilling lives. Service users have access to the local community, and through social activities and food the home has sought to meet the equalities and diversity needs of service users. EVIDENCE: Although no service users are currently in employment, one service user has requested that the home finds him employment around gardening. The home was able to evidence that it has secured suitable employment, and the service user is due to commence work their in August of this year. Three service users have booked places to attend courses at a local college starting in September of this year. One will be studying woodwork, the other two art. Two of these service users informed the inspector that they are very much looking forward DS0000007278.V345217.R01.S.doc Version 5.2 Page 14 to this opportunity, one of whom commented “I am looking forward to going to college to do painting.” Through the various activities supported and arranged by the home, the home has taken steps to help meet the equalities and diversity needs of service users. For example one service user regularly attends an African-Caribbean centre, while another attends a local Asian day centre, which arranges various day trips, and provides the opportunity to maintain and develop friendships. Another service user attends Kaleidoscope, a group run by MENCAP, which arranges various activities, including parties and discos. Two service users have recently attended training courses around relationships. These courses help to provide service users with skills to develop relationships, and to give information about appropriate relationships. Service users have the opportunity of visiting a place of worship as appropriate. Service users also have access to a variety of other social and leisure activities, such as bowling, the cinema, restaurants, pubs, playing pool and swimming. Occasional day trips are arranged, service users have recently been to Southend, and at the time of inspection service users where involved in a discussion about whether to go to Madame Tussauds or The London Dungeon. An activities programme was on display within the home, and their was evidence that service users are involved in choosing activities. Service users also have routine access to community based activities, including shops, markets, banks, post offices and public transport networks. In house service users have access to a variety of activities, including TV, DVD, music, board games, playing cards, bingo, table football and drawing. All service users are offered an annual holiday away from the home. Several service users recently had a holiday away in Great Yarmouth. Service user meetings evidenced that service users had been involved in choosing this holiday. All of the service users spoken to said how much they had enjoyed the holiday, one commented that “I went to Great Yarmouth for my holiday and had a smashing time.” Service users are able to visit their families in their own homes, including for overnight stays. Visitors are welcome at any reasonable time, and service users can see visitors in private if they so wish. Service users are given their own mail to open, and have access to a telephone. Records are maintained of menus, these indicated that service users are offered a varied, balanced and nutritious diet. Service users are involved in planning the menu, and in food preparation, including buying the food. There was evidence that the food provided helps to meet the equalities and diversity needs of service users, for example some service users prefer a Halal diet, while another enjoys Caribbean food, and there was evidence that this is catered for. Mealtimes were observed to be relaxed and flexible, on the day of inspection service users were able to choose what they had for lunch, one DS0000007278.V345217.R01.S.doc Version 5.2 Page 15 service user had jacket potatoes and tuna, another had sausage and chips, while others had a fish dish. Fresh fruit was available in the home, and service users were observed to help themselves to drinks and snacks. The kitchen was clean and tidy, and food was stored appropriately. Since the previous inspection all staff have now undertaken training in food hygiene, as has one service user who enjoys cooking. Records are maintained of fridge and freezer temperatures. DS0000007278.V345217.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 and 21. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspector’s judgement that the home is generally able to meet the health and personal care needs of service users, although it must ensure that medications are appropriately recorded. EVIDENCE: There were clear guidelines in place around the provision of individual personal care, included in service users care plans. Service users are encouraged to manage their own personal care as much as possible. On the day of inspection all service users were dressed appropriately. The home has sought and recorded the views of service users on their wishes in the event of their death. The manager informed the inspector that service users would be able to remain in the home with a terminal illness, so long as the home was able to meet their medical needs. DS0000007278.V345217.R01.S.doc Version 5.2 Page 17 All service users are registered with a GP, dentist and an optician. Records are maintained of medical appointments, including details of any follow up action required. Records indicated that service users have access to health professionals as appropriate, including psychiatrists, CPN’s, and since the previous inspection opticians. Health Action Plans are in place for all service users, these are drawn up with the involvement of their CPN’s. The home was able to evidence that it acted upon information within these plans, for example one plan identified that the service user was above their ideal weight, and that this posed potential health risks to them. The home has attempted to support this service user with a healthy eating plan, along with encouraging regular exercise. The home has an appropriate policy in place around medication, and all staff first undertake training before they are able to administer medications. Medications are stored within a locked cabinet inside the homes office. No service users currently self medicate, or are on any controlled drugs. Records are maintained of medications entering the home, and of those that are returned to the pharmacist. Medication Administration Record (MAR) charts are maintained. Where service users have been prescribed medication on a PRN basis, there are clear protocols in place around administering this. However, MAR charts indicated that one service user was administered LORAZAPAM tablets on the 8th and 10th of July 2007 on a PRN basis. This medication is only to be given when the service user is particularly agitated and distressed. The protocols for administering this medication state that when it is administered, the reason for this must be clearly recorded on the back of the MAR chart. However, on these occasions this had not been done. The daily records maintained for this service user did not provide any information as to why this medication may have been administered, indeed, for one of the two days, the daily record said that the service user was “in a good mood.” Staff on duty were unable to state why this medication had been administered. To ensure that medications are administered appropriately, and to help monitor the use of PRN, it is required that all medications that are administered are appropriately recorded. DS0000007278.V345217.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspector’s judgement that the home has suitable policies and procedures in place to help ensure that service users are safeguarded from the risk of abuse. EVIDENCE: The home has a complaints procedure in place. This includes relevant details of the CSCI, and timescales for responding to any complaints received. The home also has a complaints log, which evidenced that complaints received have been recorded and investigated as appropriate, although the manager informed the inspector that the home has not received any complaints since the last inspection. Service users spoken to demonstrated a good understanding of whom they could complain to if they so wished. The home has a copy of the Local Authorities adult protection procedures, and also its own adult protection policy. This appeared to be in line with current legislation. All but two of the staff employed at the home have undertaken adult protection training, the manager informed the inspector that the remaining two staff would have this training in the near future. Staff spoken to by the inspector were able to demonstrate a good understanding of their roles and responsibilities with regard to adult protection issues. DS0000007278.V345217.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28 and 29. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that the home is suitable to meet its stated purpose with regard to its physical environment. The home was generally well maintained, both internally and externally, and service users are provided with adequate communal and private space. 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. DS0000007278.V345217.R01.S.doc Version 5.2 Page 20 The communal space consists of a dining room, two interconnecting sitting rooms, a kitchen and garden. The home has garden furniture, which was of a suitable standard, and the garden was well maintained. The home has two bathroom/toilets and three toilets on their own. All bathrooms had working locks fitted (including an emergency override device) and were clean, tidy and free from offensive odour. The inspector was satisfied that the home has sufficient numbers of bathrooms and toilets to meet the needs of service users. 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, including table, chairs, wardrobes and a chest of draws, and meet National Minimum Standards on size requirements. The inspector was pleased to note that since the previous inspection all bedrooms are now free from offensive odour, and that two bedrooms have had new floor coverings, which service users were able to choose. The home has a policy in place on infection control. 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. COSHH products were stored securely. Service users have been provided with individual laundry baskets for their bedrooms, to help ensure they only ever wear their own clothing. DS0000007278.V345217.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 and 36. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home is staffed in sufficient numbers to meet the needs of service users, and that staff have a good understanding of their roles and responsibilities. EVIDENCE: The home provides 24-hour support, including waking night staff and an emergency on-call procedure. There was a staffing rota on display, this accurately reflected the staffing situation on the day of inspection. All staff have been provided with a copy of their job description, and of the General Social Care Council codes of conduct. There was evidence that through its recruitment practices the home has sought to meet the equalities and diversity needs of service users. The current service user group come from ethnically divers backgrounds, and this is reflected in the staff team. As mentioned, the home has recently recruited an Urdu speaking carer to help meet the needs of one of the service users. DS0000007278.V345217.R01.S.doc Version 5.2 Page 22 Through observation and discussion there was evidence that staff have built up good relations with individual service users, and that they have a good understanding of their needs. Staff were seen to interact with service users in a friendly and respectful manner. Although at times some service users made it clear they wished to be left alone, which was seen to be respected by staff, at other times staff were observed to be proactive in engaging with service users. For example, staff were seen to be showing service users photographs from the recent holiday to Great Yarmouth, and it was evident that service users were very much enjoying looking at the photos, and reminiscing about the holiday. The home has various employment related policies and procedures in place, for instance on recruitment and selection, equal opportunities and grievance and disciplinary matters. The inspector checked several staff employment files at random, all contained all necessary documentation, including proof of ID, references and CRB checks. Of the nine care staff currently employed by the home, only four of them have successfully achieved a relevant care qualification. It is required that at least 50 of care staff employed at the home have an NVQ Level 2 in Care, or equivalent qualification. Since the previous inspection all staff have now undertaken training in food hygiene. Other recent training has included working with adults with mental health and learning disabilities, and epilepsy. Staff undertake an induction programme on commencing work at the home, this includes shadowing more experienced members of staff for a two week period. The home holds regular staff meetings. These are minuted, and all staff can contribute to the agenda. A staff meeting was held on the day of inspection, and the inspector attended the first part of this meeting. It included discussions around general house issues, and also how the home could best meet the needs of service users, for example with supporting them to attend a Mosque. All staff receive regular formal one to one supervision from the homes manager. Staff are provided with a copy of the minutes from their supervision. Supervision records seen by the inspector evidenced discussions around performance, training needs and service users issues. However, at present, staff do not undertake any annual review of performance and development. The manager informed the inspector that they planned to introduce such annual reviews in the near future, and this is required. DS0000007278.V345217.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42 and 43. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspector’s view that the home has suitable management arrangements in place. The registered manager is sufficiently experienced, and they are supported by two senior care staff. EVIDENCE: The homes manager has ten years experience of working with adults with learning disabilities. They have an NVQ Level 4 in Care, and informed the inspector that they are currently working towards the Registered Managers Award. Staff were seen to interact with the manager in a relaxed manner, and service users informed the inspector that they found the manager to be accessible and approachable. DS0000007278.V345217.R01.S.doc Version 5.2 Page 24 Care plan reviews, service user meetings, staff meetings and staff supervisions all contribute to the quality assurance within the home. Copies of previous inspection reports were available to view in the home, and there was evidence of monthly Regulation 26 visits taking place. The home has issued questionnaires to service users and their relatives to gain their feedback on the running of the home. Completed questionnaires seen by the inspector contained generally positive feedback. Record keeping in the home was of a generally good standard, and up to date. Confidential records are stored securely, and staff and service users can access their records as appropriate. The home had policies and procedures as required by the National Minimum Standard. Those checked by the inspector, including recruitment and selection, medication and adult protection, were of a satisfactory standard (with the exception of the confidentiality policy which needs to be amended as already mentioned in this report). Fire extinguishers were situated around the home, these were last serviced in June 2007. Fire alarms are tested weekly, and were last serviced on the 13/10/06. Since the previous inspection the home now holds regular fire drills, on a three monthly basis. The home has a fire risk assessment in place. The home had appropriate safety certificates for gas safety, electrical installation and PAT testing. COSHH products within the home were stored securely. The home had in date employer’s liability insurance cover. Fridge/freezer and hot water temperatures are checked as appropriate. DS0000007278.V345217.R01.S.doc Version 5.2 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 Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 X STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 2 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 3 3 3 3 3 3 DS0000007278.V345217.R01.S.doc Version 5.2 Page 26 No. 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 YA8 Regulation 12 and 23 Requirement The registered person must ensure that service users have the opportunity of choosing new curtains for the sitting room, in line with their stated preference. The registered person must ensure that the homes confidentiality policy makes clear under what circumstances a confidence may be broken in the health, safety and welfare interests of service users and others. The registered person must ensure that any medications administered are appropriately recorded. The registered person must ensure that at least 50 of care staff employed at the home have an NVQ Level 2 in Care or equivalent qualification. The registered person must ensure that all staff have an annual appraisal of their performance and development needs, which is subject to regular review. Timescale for action 31/10/07 2. YA10 13 30/09/07 3. YA20 13 31/07/07 4. YA32 18 31/12/07 5. YA36 18 31/10/07 DS0000007278.V345217.R01.S.doc Version 5.2 Page 27 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 Standard Good Practice Recommendations DS0000007278.V345217.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU National Enquiry Line: 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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