Inspection on 19/06/06 for Lakeside House

This inspection was carried out on 19th June 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 26 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 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 Key Unannounced Inspection 19th June 2006 10:00 Lakeside House DS0000007278.V296788.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 Lakeside House DS0000007278.V296788.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. Lakeside House DS0000007278.V296788.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 ****Post Vacant**** Care Home 8 Category(ies) of Learning disability (7), Mental disorder, registration, with number excluding learning disability or dementia (1) of places Lakeside House DS0000007278.V296788.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd February 2006 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. Lakeside House DS0000007278.V296788.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 19/6/06 and was unannounced. The inspector had the opportunity of speaking with service users and staff from the home. The homes acting manager was present throughout the inspection. Despite some improvements since the last inspection, the home is still some way short of been in line with all National Minimum Standards and the Care Home Regulations 2001. This is reflected by the relatively high number of requirements, twenty six, set at this inspection. 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. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lakeside House DS0000007278.V296788.R01.S.doc Version 5.2 Page 6 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 Lakeside House DS0000007278.V296788.R01.S.doc Version 5.2 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that through written documentation and the opportunity of visiting the home service users are able to make an informed choice as to move in or not. However, the home must not admit service users from outside its category of registration. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place. The Statement includes details of the staff team and the organizational structure and the aims and objectives of the home. The Statement has been reviewed since the last inspection. However, it is still not in line with National Minimum Standards (NMS) and the Care Homes Regulations 2001, for example it states that the home is registered for adult placement, yet this is not the case. The Service User Guide includes details of the physical environment and services provided, and since the last inspection now includes a copy of the homes complaints procedure. All service users have been provided with a contract/statement of terms and conditions. These have been signed by the service users, and are in line with NMS. Although there have been no new admissions to the home since the last inspection, the home now has a comprehensive admissions procedure in place. This states that the homes manager will carry out a pre admission assessment Lakeside House DS0000007278.V296788.R01.S.doc Version 5.2 Page 8 of the service users needs, and that they will be given the opportunity of visiting the home prior to making a decision as to move in or not. The home is registered to provide accommodation to seven adults with learning disabilities, and one adult with mental health issues. However, currently there is one service user with mental health issues, six with learning difficulties and one service user with a dual diagnosis of both learning disabilities and mental health issues. It is required that if this service user is to remain in the home, then the home must apply to the CSCI for a minor variation to demonstrate how the home can meet their assessed needs. It is further required that the home does not admit any further service users from outside its category of registration. Lakeside House DS0000007278.V296788.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments were of a generally satisfactory standard, however, the home must be able to demonstrate how service users are involved in the day to day running of the home. EVIDENCE: A new system of care planning has been introduced in the home since the previous inspection. Care plans are now of a satisfactory standard, and were clear and comprehensive. Plans are drawn up with the involvement of the service user, their keyworker and the homes manager. Plans include needs associated with medication, mobility, culture and social and leisure needs. There was evidence that plans are subject to regular review. At the previous inspection it was required that the home ensures that all service user have a review meeting in conjunction with their placing authority, at least annually. On the day of inspection one such meeting took place. However, two service users have had no such meetings within the past year, and no dates had been arranged for them in the near future. It is a repeat Lakeside House DS0000007278.V296788.R01.S.doc Version 5.2 Page 10 requirement that all service users have at least an annual review with their placing authority. Risk assessments are in place for all service users. These are clear and easy to understand, and include strategies to manage and reduce any risks. However, as at the last inspection these are still not comprehensive. For example, records indicated that the GP of one service user considered them to be at high risk of heart disease and diabetes due to their weight. The acting manager informed the inspector that the home was fully aware of this issue, and was taking steps to address the situation, yet there was no risk assessment in place around this. It is required that comprehensive risk assessments are in place for all service users, covering all areas of potential risks to themselves and others. There was evidence that service users have control over their daily lives, for example on the day of inspection service users were observed to get up at a time of their choosing, and were consulted over what they wanted for lunch. The acting manager informed the inspector that service users were regularly consulted over the running of the home, for instance over menus, activities and shopping. However, systems in place to record any consultation with service users were severely limited. The inspector was informed that the home was supposed to have monthly service user meetings, but there has been only one such meeting since September 2005. It is required that service users are routinely consulted over the running of the home, and that this consultation is recorded. The home has a confidentiality policy in place. This makes clear under what circumstances a confidence may have to be broken in the health, safety and welfare interests of service users and others. Staff spoken to demonstrated a good understanding of the issues involved around confidentiality. Staff and service users can access their records. However, although all service user’s records were stored appropriately, this was not the case for confidential staff records, and this must be addressed. Lakeside House DS0000007278.V296788.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. It is the inspector’s judgement that service users are generally supported to live fulfilling lives, for example through appropriate social and educational opportunities. EVIDENCE: The acting manager informed the inspector that service users were involved with in-house programmes to help develop their independence, for example around cooking and laundry skills. Yet there were no plans or guidelines in place around this, thus making it very difficult to ensure a consistent approach to staff supporting these activities and to measure any progress made, and this must be addressed. Two service users currently attend a local college where they study IT skills. Other service users spoken to on the day of inspection expressed an interest in attending college. The acting manager has arranged to support service users to attend a college open day, with a view to choosing courses to attend when the college re-opens after the summer break. No service users currently wish to be involved in any formal employment opportunities. Lakeside House DS0000007278.V296788.R01.S.doc Version 5.2 Page 12 Service users are able to access the local community. One service user attends an African-Caribbean centre, where they socialise with friends, and take part in activities such as day trips, while another service user attends a local Asian social group. Another service user is a member of a local social club run by MENCAP, they attend its meetings and are involved in planning its activities. Service users access local transport networks, including buses and mini-cabs, and the home has its own unmarked transport which service users use to access the community. The inspector was pleased to note that the level of social and leisure activities provided by the home has increased considerably since the previous inspection. In house service users now have a DVD player and music system in the sitting room, along with TV. On the day of inspection service users were observed to play darts and cards, and a game of bingo was arranged. In the community service users are supported to go swimming, bowling, out to lunch and for walks. The home has arranged for all service users to go on a weeks holiday to Blackpool in August of this year. Service users spoken to informed the inspector that they were very much looking forward to this. There was evidence that service users are able to see any visitors to the home in private if they so wish. Service users regularly visit their family, including for overnight stays. The inspector was informed that service users are given their own mail to open, and on the day of inspection service users were observed to use a telephone in private. Records are maintained of menus, these indicated that service users are offered a varied, balanced and nutritious diet. Three service users are on a Halal diet, and this is appropriately catered for. Service users are involved in choosing and buying food, and on the day of inspection were observed to help themselves to drinks and snacks. Fresh fruit was available. The kitchen was clean and tidy, and food was stored appropriately. Records are maintained of fridge and freezer temperatures. Mealtimes were observed to be relaxed and unhurried. Lakeside House DS0000007278.V296788.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20 and 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home has generally taken reasonable steps to ensure the health care needs of service users are met, although the home must ensure that service users have regular access to dental care. EVIDENCE: All service users are registered with a GP. Records are maintained of any medical appointments, these include details of any follow up action required. Records indicated that service users have access to GP’s, dieticians and psychiatrists, however, for several service users there was no evidence that they have regular access to dental care, and this must be addressed. The home has a comprehensive medication policy, and all staff undertake training before they are able to administer medications. Medications are stored within a locked cabinet in the office. Records are maintained of medications entering the home and of those that are returned to the pharmacist. No service users currently self medicate or are on any controlled drugs. Guidelines are in place on the administration of medications prescribed on a PRN basis. Medication Administration Record (MAR) charts are maintained. These Lakeside House DS0000007278.V296788.R01.S.doc Version 5.2 Page 14 appeared to be accurate and up to date, and since the last inspection hand written entries on MAR charts are now signed for. The home has sought and recorded the views of service users on their wishes in the event of their death. The acting manager informed the inspector that service users would be able to remain in the home with a terminal illness, as long as the home was able to meet their medical needs. Lakeside House DS0000007278.V296788.R01.S.doc Version 5.2 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 the following standard(s): 22 and 23 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The inspector believes that service users are been put at potential risk by the homes lack of policies and procedures with regard to adult protection, and by staffs poor understanding of the issues involved around adult protection. EVIDENCE: The home has a complaints procedure. This makes appropriate reference to the CSCI, and includes timescales for responding to any complaints received. All service users are given their own copy of the procedure, and since the last inspection it is now on display within the home. There is also a complaints log in the home. This evidenced that complaints received have been appropriately recorded and investigated. The inspector was disappointed to note that the home did not have its own adult protection procedure, nor did it have a copy of the Local Authorities adult protection procedures. Both of these issues must be addressed as a matter of urgency. Further, staff spoken to on the day of inspection demonstrated a poor understanding of their roles and responsibilities with regard to adult protection. All staff must undertake training in adult protection issues, and have a good understanding of their responsibilities with regard to adult protection issues. The home keeps money on behalf of service users in a locked cabinet. The inspector checked several service users monies at random, records and receipts are maintained, and these all appeared to be satisfactory. Lakeside House DS0000007278.V296788.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. It is the inspector’s view that the home is suitable to meet its stated purpose with regard to the physical environment. The home was generally well maintained, 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. The communal space consists of a dining/sitting room, kitchen and garden. Since the last inspection the garden furniture has been replaced, and is now of a suitable quality. 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, and the damaged floor covering in the upstairs bathroom has been repaired. All service users have their own bedrooms. Bedrooms have hand basins in them, and adequate natural light and ventilation. Bedrooms have been Lakeside House DS0000007278.V296788.R01.S.doc Version 5.2 Page 17 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. One service user informed the inspector that they would like a key to their bedroom. The acting manager informed the inspector that this would be arranged, and it is required that all service users are offered keys to their bedrooms, subject to the completion of satisfactory risk assessments. 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. Since the last inspection service users have been provided with individual laundry baskets for their bedrooms. Lakeside House DS0000007278.V296788.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 and 36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. It is the inspector’s judgement that staffing levels are too low, and that staff would further benefit from attending training relevant to their jobs. EVIDENCE: The home provides 24-hour support including an emergency on-call system. There was a staffing rota on display, but this did not accurately reflect the actual staffing situation on the day of inspection. For example, it did not record the hours worked in the home by the acting manager, and it is required that the staffing rota accurately records the hours worked in the home by all staff. Further, the rota did not identify who was in charge of the home at any given time, and this must be addressed. At the last inspection a requirement was made that the home review its staffing levels to determine how it can meet the assessed needs of service users at all times. This has not been done. The inspector has concerns that staffing levels are currently insufficient. Five days a week the home has only two staff on duty between the hours of 9am and 3pm. These staff are expected to carry out all necessary personal care duties, cooking, cleaning and other domestic duties, paperwork, administration of medications, answering phones, dealing with any visitors to the home and supporting service users with any appointments they may have. This leaves very little time for any meaningful Lakeside House DS0000007278.V296788.R01.S.doc Version 5.2 Page 19 interaction with service users, and the requirement that staffing levels are reviewed is therefore repeated in this report. The home has policies in place on equal opportunities and recruitment and selection. At the last inspection a recommendation was made that service users are given the opportunity of been involved in the recruitment of all staff to the home. This is still not happening, therefore the recommendation is repeated. The inspector checked several staff employment files at random, and found they contained evidence of satisfactory CRB checks and employment references. However, several did not contain any proof of ID, or a full written record of staffs employment history, including details of any gaps in employment, and this must be addressed. The acting manager joined the home on the 13/2/06, and at the time of inspection they informed the inspector that they had still not been given a copy of their job description. It is required that all staff are provided with a copy of their job description, detailing their roles and responsibilities, on commencing work at the home. Staff have been provided with a copy of the General Social Care Council codes of conduct. Since the last inspection staff have undertaken training in first aid, challenging behaviour and food hygiene. However, staff have not received training in all statutory health and safety matters, for instance several staff have not received any recent training in fire safety. Further, as at the last inspection, staff have not had any training around mental health, learning disabilities and epilepsy. All of this must be addressed. The acting manager informed the inspector that four of the eight care staff employed at the home have obtained a relevant qualification in care, and that it was planned that all staff would be given the opportunity of achieving such a qualification. The inspector was disappointed to note that records indicated that most staff have had only one formal supervision in the past year. It is required that staff receive regular formal supervision, at least six times a year. Lakeside House DS0000007278.V296788.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40,42 and 43 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There are virtually no quality assurance systems in place, and much improvement is needed around fire safety issues. EVIDENCE: Since the previous inspection a new manager has been appointed to the home. They informed the inspector that it was intended that they would apply for registration with the CSCI in the near future, and this is required. The acting manager informed the inspector that they planned to introduce a quality assurance system in the home, that would include seeking the views of service users on the level of care and support they receive, to help inform future planning, and this is required. The inspector was disappointed to note that the homes proprietor has carried out only three Regulation 26 visits in the past year. It is required that these are done monthly, that they are done by the proprietor, and that they are unannounced. It is further required that a Lakeside House DS0000007278.V296788.R01.S.doc Version 5.2 Page 21 report of these visits is forwarded to the CSCI, and that a copy is retained in the home. At the last inspection a requirement was set that the home has all necessary policies and procedures in line with the National Minimum Standards and the care Homes Regulations 2001. This requirement has not been met, for example the home had no policies on adult protection or quality assurance, and is consequently repeated in this report. The inspector has concerns over the level of fire safety within the home. Fire extinguishers used to be situated around the home; these have now been removed to the office. The inspector was informed this was because a service user had used them to smash windows. It is required that the home arranges for the Local Fire Authority to visit the home to give guidance on this issue. Further, there was no evidence that the home carries out weekly checks on its fire alarms, or that it holds regular fire drills. The home did not have a fire risk assessment in place, or an appropriate fire safety policy. All of this must be addressed urgently. The home tests fridge/freezer and hot water temperatures, and COSHH products were stored securely. The home has had in date PAT, gas and electrical installation safety checks carried out. The home had in date employer’s liability insurance cover. Lakeside House DS0000007278.V296788.R01.S.doc Version 5.2 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 Standard No Score 1 2 2 X 3 2 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 1 ENVIRONMENT Standard No Score 24 3 25 3 26 2 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 2 32 3 33 1 34 2 35 1 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 2 2 2 LIFESTYLES Standard No Score 11 2 12 3 13 3 14 3 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 2 3 3 2 X 1 2 X 1 3 Lakeside House DS0000007278.V296788.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 4 Requirement The registered person must ensure the homes Statement of Purpose is developed in line with Schedule 1 of the Care Homes Regulations 2001. (Timescale 31/05/06 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, and the registered person must ensure that regular service user meetings are held. (Timescale 31/05/06 not met) The registered person must ensure that comprehensive risk 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 and fully implemented. (Timescale 31/05/06 not met) The registered person must ensure that all service users are offered keys to their bedrooms, subject to satisfactory risk assessments. (Timescale DS0000007278.V296788.R01.S.doc Timescale for action 31/10/06 2. YA8 12 31/10/06 3. YA9 13 31/10/06 4. YA16 12 31/10/06 Lakeside House Version 5.2 Page 24 31/05/06 not met) 5. YA23 13 The registered person must ensure that the home has a policy and procedure on adult protection and that it is in line with current legislation. Further, the registered person must ensure that the home has a copy of the Local Authorities adult protection procedures. (Timescale 31/05/06 not met) The registered person must ensure that all staff employed at the home receive appropriate training around adult protection issues. (Timescale 31/05/06 not met) The registered person must ensure that the home has a full written records of staffs employment history, including an explanation of any gaps in employment. (Timescale 31/05/06 not met) 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. (Timescale 31/05/06 not met) The registered person must ensure that all staff receive all statutory health and safety training as appropriate. (Timescale 31/05/06 not met) 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 the supervision. (Timescale 31/05/06 not met) The registered person must appoint a suitably qualified and experienced manager to the DS0000007278.V296788.R01.S.doc 31/08/06 6. YA23 13 31/10/06 7. YA34 19 31/10/06 8. YA35 18 31/10/06 9. YA35 18 31/10/06 10. YA36 18 31/10/06 11. YA37 8 and 9 31/10/06 Lakeside House Version 5.2 Page 25 12. YA39 26 13. YA40 17 14. YA33 18 15. YA39 24 16. YA42 13 and 23 17. YA42 13 and 23 18. YA3 14 home, and apply for their registration with the CSCI. (Timescale 31/05/06 not met) 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. (Timescale 31/05/06 not met) 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. (Timescale 31/05/06 not met) The registered person must carry out a review of staffing levels to ensure that there are sufficient staff on duty at all times to meet service users assessed needs. (Timescale 31/05/06 not met) The registered person must ensure that the home has appropriate quality assurance systems in place, which include seeking the views of service users on the running of the home. (Timescale 31/05/06 not met) The registered person must ensure that the home has an appropriate fire safety policy in place. (Timescale 31/05/06 not met) The registered person must ensure that the home tests and records the fire alarms at least once a week. (Timescale 31/05/06 not met) The registered person must ensure that the home does not admit service users from outside DS0000007278.V296788.R01.S.doc 31/10/06 31/10/06 31/10/06 31/10/06 31/08/06 31/08/06 31/08/06 Lakeside House Version 5.2 Page 26 its category of registration. 19. YA3 14 The registered person must ensure that it has appropriate conditions of registration for all current service users. The registered person must ensure that all confidential records are stored securely. The registered person must ensure that clear written guidelines are in place on any programmes to develop individual service users independence. The registered person must ensure that service users have access to all health care professionals as appropriate, including dental care. The registered person must ensure that all staff are provided with a copy of their job description, detailing their roles and responsibilities. The registered person must ensure that the homes staffing rota accurately records the hours worked in the home by all staff, including the manager, and that it clearly identifies who is in charge of the home at any given time. The registered person must ensure that the home obtains appropriate proof of ID (passport and birth certificate) for all staff prior to them commencing work at the home. The registered person must ensure the following: 1)The registered person must arrange for the Local Fire Authority to visit the home to advise on the best place to keep fire extinguishers within the home. 2) The registered person must ensure that the home carries out DS0000007278.V296788.R01.S.doc 31/10/06 20. 21. YA10 YA11 17 15 31/10/06 31/10/06 22. YA19 13 31/10/06 23. YA31 18 31/10/06 24. YA33 17 31/10/06 25. YA34 19 31/10/06 26. YA42 13 and 23 31/10/06 Lakeside House Version 5.2 Page 27 regular fire drills, at least once every three months. 3) The registered person must ensure that the home carries out regular fire drills, at least once every three months. 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 YA8 Good Practice Recommendations It is recommended that service users at the home are given the opportunity of been involved in the recruitment and selection of all staff to the home. Lakeside House DS0000007278.V296788.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ 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 DS0000007278.V296788.R01.S.doc Version 5.2 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!