Inspection on 02/02/06 for Lakeside House

This inspection was carried out on 2nd February 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 38 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 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 2 February 2006 10:00 nd Lakeside House DS0000007278.V275553.R01.S.doc Version 5.1 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.V275553.R01.S.doc Version 5.1 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.V275553.R01.S.doc Version 5.1 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.V275553.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st August 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 DS0000007278.V275553.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 2/2/06 and was unannounced. The inspector had the opportunity of speaking with service users, staff from the home and the homes deputy manager was present throughout the inspection. Despite some improvements since the previous inspection the inspector was very disappointed with the overall level of care and support provided by the home. This is reflected by the relatively high number of requirements set, many of which 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. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lakeside House DS0000007278.V275553.R01.S.doc Version 5.1 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.V275553.R01.S.doc Version 5.1 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 and 4 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 in place. Since the last inspection both documents have been dated and subject to review. The Statement includes details of the organisation and its aims and objectives. However, it is still not in line with National Minimum Standards (NMS), for example it states that the home is registered for adult placement, but this is not the case. The Service User Guide also needs further amendments, for example it does not include a copy of the homes complaints procedure. It is also a repeat requirement that both documents are produced in a format that is accessible to service users. At present both are written in English, but the inspector was informed that several service users are unable to access documentation in this format. At the previous inspection the proprietor outlined the homes admission procedure. They informed the inspector that it would include existing service users views been sought on the suitability of any prospective new service user, and that they would initially move in on a trial basis, after which a placement Lakeside House DS0000007278.V275553.R01.S.doc Version 5.1 Page 8 review meeting would be held. At this inspection the deputy manager confirmed that this was still the case. It is therefore required that the homes admissions procedure is updated to reflect the actual admissions procedure. There have been no new admissions to the home since the last inspection. Lakeside House DS0000007278.V275553.R01.S.doc Version 5.1 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): 6,8 and 9 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. These are clear and easy to understand, and are drawn up with the involvement of service users, keyworkers and the homes deputy manager. However, plans still need further development to set out how the home can meet the assessed needs of service users. For instance, one plan indicated that the service user’s GP had recommended that they loose two stone in weight due to health concerns, yet the care plan gave no indication of what steps were to be taken to encourage this weight loss. Further, several plans did not include any information on how the home is able to meet service users social and leisure needs. It is required that plans are comprehensive, and clearly set out how the home can meet all of service users assessed needs. At the last inspection a requirement was set that each service user has a review meeting in conjunction with their placing Lakeside House DS0000007278.V275553.R01.S.doc Version 5.1 Page 10 authority at least annually, this has not been done, and is therefore repeated. Guidelines have been put in place since the last inspection around the managing of challenging behaviours that service users may exhibit. Risk assessments were clear and comprehensive, and of a satisfactory standard. Assessments cover risks associated with fire, falling and accessing the community. Risk assessments are subject to regular review, and set out strategies for minimising any risks identified. However, strategies are not always implemented. For example, one service user has epilepsy. It has been identified by their CPN that they should be checked in their sleep every 15 minutes, and there are clear guidelines in place around this in their risk assessment. However, records indicated that they are checked far less frequently then every 15 minutes, and indeed some nights they are not checked at all. It is required that risk assessments are fully implemented. The inspector was disappointed to note the lack of service user involvement in the running of the home. For example, there has only been one service user meeting in the past year, and decisions taken at this meeting have not been acted upon, for instance at the meeting service users stated that the would like a DVD player for the home. The meeting was held in September 2005 and there are no plans to obtain a DVD player at the time of this inspection. The home recently obtained a new sofa for the sitting room, staff informed the inspector that service users had not been given the opportunity of been involved in choosing the new sofa. The inspector spoke with a member of the staff team who was recruited in November 2005, they informed the inspector that no service users were involved in the recruitment process. It is recommended that service users are given the opportunity of been involved in the recruitment of all staff to the home. Lakeside House DS0000007278.V275553.R01.S.doc Version 5.1 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): 11,12,14,15 and 16 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: Two service users attend a local college where they study IT. No other service users are involved in any employment or formal educational opportunities. However, one service user expressed a strong desire to attend college to study art classes. Staff informed the inspector that they were aware of this service users wishes, yet there was no evidence that anything has been done to arrange art classes. It s required that the home provides appropriate educational opportunities for service users in line with their assessed needs and stated preference. The deputy manager informed the inspector that service users were involved with in-house schemes to help develop their independence, for example around laundry and cooking skills. Yet there were no guidelines in place around this, indeed there was no documentary evidence Lakeside House DS0000007278.V275553.R01.S.doc Version 5.1 Page 12 that these scheme existed at all, and this must be addressed. At the last inspection a service user informed the inspector that they would like to attend mosque regularly. This service user was not present during the course of this inspection, but records indicated that they were still not been given the opportunity of attending mosque, and it is required that the home supports service users to attend a place of worship of their choice. In house service users play bingo, board games and watch TV. Service users informed the inspector that they would like to play music in the sitting room, and watch films in the sitting room. However, the home does not have a music system or DVD player in the sitting room and this must be addressed. The home organises parties, for example to celebrate service users birthdays. In the community three service users attend a sports club on Saturday morning run by the Local Authority, where they play snooker and bowling, while another service user attends a local African-Caribbean centre. However, there was very little evidence of any community based social and leisure activities provided by the home. Records indicated that it was not unusual for some service users to spend an entire week at home, without been given the opportunity of participating in community based social and leisure activities. It is a repeat requirement that this is addressed. Continued failure to address this issue may lead the CSCI to consider taking enforcement action against the home in the future. 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, and since the last inspection this is now 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. 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. Lakeside House DS0000007278.V275553.R01.S.doc Version 5.1 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 and 20 The inspector was satisfied that the home is able to meet the health care needs of service users. Service users have access to health care professionals as appropriate, and medications were stored, recorded and administered in an appropriate manner. 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. The deputy manager informed the inspector that since the last inspection visiting health professionals will now see service users in private. The inspector was pleased to note that there has been a considerable improvement with regard to medication issues in the home since the last inspection. The home now has a comprehensive mediation policy, and all staff undertake a thorough training course before they are able to administer medications. Medications are stored within a locked cabinet. No service users are currently on any controlled medications or self medicate. Records are kept of medications entering the home and of those that are returned to the pharmacist. Clear guidelines were in place around medications that are prescribed on a PRN basis. Medication Administration Record (MAR) charts are Lakeside House DS0000007278.V275553.R01.S.doc Version 5.1 Page 14 maintained, these appeared to be accurate and up to date. However, hand written entries on MAR charts were not always signed, and this must be addressed. Lakeside House DS0000007278.V275553.R01.S.doc Version 5.1 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 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 log, although the deputy manager informed the inspector that no complaints have been received since the last inspection. The home has a complaints procedure, this has been updated since the last inspection and now includes contact details of the CSCI. However, the procedure was not on display within the home and this is recommended. Further, it was not produced in a format that is not accessible to many service users, and this must be addressed. Although the home has a copy of the Local Authorities adult protection procedure, it does not have its own policy on adult protection, and this is required. The deputy manager informed the inspector that none of the current care staff have received training in adult protection issues, and this must be addressed as a matter of urgency. The home holds money on behalf of service users in a locked cabinet. Records and receipts are maintained of transactions involving service user’s money. The inspector checked several sets of monies and records, one service user was found to be £1.70 short, while another was £2.30 over. It is required that clear systems are in place for checking service user’s monies to help ensure that it is correct and spent appropriately. Lakeside House DS0000007278.V275553.R01.S.doc Version 5.1 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 The inspector was satisfied that the home’s physical environment is suitable to meet its stated purpose. Service users are provided with adequate communal and private space, and the home was 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, however, the garden furniture was in a very poor state of repair and must be replaced. 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 since the last inspection. 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 Lakeside House DS0000007278.V275553.R01.S.doc Version 5.1 Page 17 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. 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. However, the COSHH cupboard was unlocked on the day of inspection, and it is required that COSHH products are stored securely. Further, service users did not have individual laundry baskets in their bedrooms, even though several service users have requested this. It is required that individual laundry baskets are provided for service users. Lakeside House DS0000007278.V275553.R01.S.doc Version 5.1 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): 33,34,35 and 36 The inspector has serious concerns over staffing arrangements in the home. It is the inspectors belief that staffing levels are currently inadequate to meet service users needs. Further, the home must ensure that staff receive appropriate training and supervision. EVIDENCE: The home provides 24-hour support, including a waking night staff. Since the last inspection the home now has an emergency on-call procedure. However, the inspector was very disappointed to note that staffing levels have decreased since the previous inspection. At the last inspection the home had three staff on duty on every early shift, between 9am and 3pm, this has now been cut to only two staff on the early shift four days a week. The deputy manager informed the inspector that they felt current staffing levels were now inadequate, and the inspector shares this view, especially in relation to the poor standard of record keeping and the lack of community based social and leisure activities on offer. It is required that the home carries out a review of staffing levels to determine how the home can meet the assessed needs of service users at all times. The home has policies in place on equal opportunities and recruitment and selection. The most recent staff member to be recruited to the home informed the inspector that they were interviewed by just one person, which is not in line with good practice as regards equal opportunities, and it is required that Lakeside House DS0000007278.V275553.R01.S.doc Version 5.1 Page 19 all staff recruitment is carried out in line with good practice as regards equal opportunities. The inspector checked several staff employment files at random, these contained evidence of satisfactory CRB checks, employment references and proof of ID. However, files did not contain a full written record of staff’s employment history, and this must be addressed. Records are maintained of staff training, these evidenced that staff have undertaken recent training in care planning and medication. However, the overall level of training provided is very limited. Service users have learning disabilities, mental health issues and epilepsy, and at the last inspection it was required that staff undertake training around these areas, yet none of this has happened. Further, many staff have not had any recent health and safety training in fire safety, first aid, manual handling and food hygiene. It is required that staff receive all necessary statutory health and safety training. At present staff do not have an annual training plan, and this must be addressed. None of the staff team have received any formal supervision at all since the last inspection, and it is required that all staff receive regular formal supervision, at least six times a year. Lakeside House DS0000007278.V275553.R01.S.doc Version 5.1 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): 37,39,40,41,42 and 43 The inspector was not satisfied that the home has satisfactory management arrangements in place. Record keeping and policies are of a poor standard, and there is no permanent registered manager in place. EVIDENCE: At present the home does not have a manager, the day to day running of the home is been carried out by the deputy manager. The proprietor informed the inspector that he has recently recruited someone who he plans to employ as the manager of the home. It is required that the home has a permanent manager in place, and that this manager is registered with the CSCI. The home does not have a quality assurance policy in place, and there was very little evidence of any systems in place to ensure quality assurance. There have only been two Regulation 26 visits carried out in the past year, and it is required that these are done monthly, and that a copy of the report is sent to the home and that a copy is forwarded to the CSCI. There are no mechanisms in place for seeking the views of staff, service users or relatives on the running Lakeside House DS0000007278.V275553.R01.S.doc Version 5.1 Page 21 of the home. It is required that the home introduces quality assurance systems, which include seeking the views of service users, 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 quality assurance and adult protection. This must be addressed. The inspector also had concerns around the poor standing of record keeping in the home, for instance care plans have not been kept up to date. Records are however held securely as appropriate. Fire fighting equipment was situated around the home and last serviced in June 2005. Fire alarms were last serviced on the 10/10/05. There was evidence of regular fire drills, although fire alarms are not tested by the home and this must be done at least weekly. Further, the home does not have a fire safety policy and procedure and this must be addressed. The home had in date certificates on electrical installation and PAT, but did not have an in date gas safety certificate, and this must be addressed. Hot water and fridge/freezer temperatures are checked appropriately. The home has in date employer’s liability insurance cover. Lakeside House DS0000007278.V275553.R01.S.doc Version 5.1 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 X 4 2 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 2 29 3 30 2 STAFFING Standard No Score 31 X 32 X 33 1 34 2 35 1 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X 1 2 X LIFESTYLES Standard No Score 11 1 12 2 13 X 14 1 15 3 16 2 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 2 X 1 X 1 2 2 2 3 Lakeside House DS0000007278.V275553.R01.S.doc Version 5.1 Page 23 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard 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 30/11/05 not met) The registered person must ensure service users have access to and choose from a appropriate leisure activities. (Timescale 30/11/05 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 30/11/05 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 30/11/05 not met) The registered person must in discussion with service users enable them to take part in DS0000007278.V275553.R01.S.doc Timescale for action 31/05/06 2 YA14 16 31/05/06 3 YA1 4 31/05/06 4 YA8 12 31/05/06 5 YA12 16 31/05/06 Lakeside House Version 5.1 Page 24 6 YA14 16 7 YA22 22 8 YA4 14 9 YA6 15 10 YA6 15 11 YA8 12 12 YA9 13 learning opportunities appropriate to their need. (Timescale 30/11/05 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 30/11/05 not met) The registered person must review the format of the complaints procedure to ensure that it is accessible to service users. (Timescale 30/11/05 not met) The registered person must ensure that the homes admissions procedure accuratley reflects the actual practice of admitting service users to the home. (Timescale 30/11/05 not met) 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. (Timescale 30/11/05 not met) The registered person must ensure that the home holds regular review meetings for all service users, at least once a year, in conjunction with the placing authority. (Timescale 30/11/05 not met) The registered person must ensure that regular service user meetings are held. (Timescale 30/11/05 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. DS0000007278.V275553.R01.S.doc 31/05/06 31/05/06 31/05/06 31/05/06 31/05/06 31/05/06 31/05/06 Lakeside House Version 5.1 Page 25 (Timescale 30/11/05 not met) 13 YA11 12 The registered person must ensure that arrangements are in place to enable service users to visit a place of worship of their choice. (Timescale 30/11/05 not met) The registered person must ensure that the home supports service users to participate in appropriate educational opportunities in line with their assessed needs and stated preference. (Timescale 30/11/05 not met) The registered person must ensure that all service users are offered keys to their bedrooms, subject to satisfactory risk assessments. (Timescale 30/11/05 not met) The registered person must ensure that all hand written entries on MAR charts are signed for. (Timescale 30/11/05 not met) 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. (Timescale 30/11/05 not met) The registered person must ensure that all staff employed at the home receive appropriate training around adult protection issues. (Timescale 30/11/05 not met) The registered person must ensure that all staff recruitment is carried out in line with good practice with regards to equal opportunities. (Timescale 30/11/05 not met) The registered person must ensure that the home has a full written records of staffs DS0000007278.V275553.R01.S.doc 31/05/06 14 YA12 16 31/05/06 15 YA16 12 31/05/06 16 YA20 13 31/05/06 17 YA23 13 31/05/06 18 YA23 13 31/05/06 19 YA34 19 31/05/06 20 YA34 19 31/05/06 Lakeside House Version 5.1 Page 26 21 YA35 18 22 YA35 18 23 YA36 18 24 YA37 8 and 9 25 YA39 26 26 YA40 17 employment history, including any gaps in employment. (Timescale 30/11/05 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 30/11/05 not met) The registered person must ensure that all staff receive all statutory health and safety training as appropriate. (Timescale 30/11/05 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 30/11/05 not met) The registered person must appoint a suitably qualified and experienced manager to the home, and apply for their registration with the CSCI. (Timescale 30/11/05 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 30/11/05 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 30/11/05 not met) DS0000007278.V275553.R01.S.doc 31/05/06 31/05/06 31/05/06 31/05/06 31/05/06 31/05/06 Lakeside House Version 5.1 Page 27 27 YA41 17 28 YA14 23 29 YA23 13 30 YA28 23 31 32 YA30 YA30 13 16 33 YA33 18 34 YA35 18 35 YA39 24 The registered person must ensure that the home maintains all records required by the National Minimum Standards and the Care Home Regulations 2001. (Timescale 30/11/05 not met) The registered person must ensure that the home has a working DVD and CD player in the sitting room in line with service users wishes. The registered person must ensure that systems are in place to ensure that money held by the home on behalf of service users is appropriatly spent and accounted for. The registered person must ensure that the garden furniture which is in in a poor state of repair is replaced. The registered person must ensure that all COSH products are stored securely. The registered person must ensure that service users are provided with their own individual laundry basket in line with their wishes. The registered person must carry out a review of staffing levels to ensure that there are suffcient staff on duty at all times to meet service users assessed needs. The registered person must ensure that all staff have an individual training plan that is reviewd at least annualy and fully implemented where appropriate. 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.. DS0000007278.V275553.R01.S.doc 31/05/06 31/05/06 31/05/06 31/05/06 31/05/06 31/05/06 31/05/06 31/05/06 31/05/06 Lakeside House Version 5.1 Page 28 36 YA42 13 and 23 37 YA42 13 38 YA42 13 and 23 The registered person must ensure that the home has an appropriate fire safety policy in place. The registered person must ensure that the home has a gas safety check carried out at least once every twelve months. The registered person must ensure that the home tests and records the fire alarms at least once a week. 31/05/06 31/05/06 31/05/06 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 2 Refer to Standard YA8 YA22 Good Practice Recommendations 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 DS0000007278.V275553.R01.S.doc Version 5.1 Page 29 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.V275553.R01.S.doc Version 5.1 Page 30 - 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. 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